NQF

Version Number: 1.9
Meeting Date: December 12-13, 2015

Measure Applications Partnership
Clinician Workgroup Discussion Guide

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Agenda

Agenda Synopsis

Day 1  
8:30 am   Breakfast
9:00 am   Welcome, Disclosures of Interest, Review of Meeting Objectives
9:15 am   Pre-Rulemaking Opening Remarks
9:45 am   NQF Strategic Plan
10:00 am    Overview of Pre-Rulemaking Approach
10:15 am   Overview of the Medicare Shared Savings Program (MSSP)
10:30 am   Break
10:45 am   Opportunity for Public Comment on Smoking measure (for MSSP and MIPS) under consideration
11:00 am   Pre-Rulemaking Input on the Medicare Shared Savings Program measure under consideration
11:15 am   Feedback on Current MSSP Measure Set
12:00 pm   Lunch
12:45 pm   Overview of the Merit-Based Incentive Payment System (MIPS)
1:00 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Smoking
1:15 pm   Opportunity for Public Comment on HIV measures under consideration
1:25 pm   Pre-Rulemaking Input on the MIPS measure under consideration- HIV
2:10 pm   Opportunity for Public Comment on Cardiology measures under consideration
2:20 pm   Pre-Rulemaking Input on the MIPS measures under consideration- Cardiology
2:50 pm   Break
3:05 pm   Opportunity for Public Comment on Cancer measures under consideration
3:15 pm   Pre-Rulemaking Input on the MIPS measures under consideration- Cancer
4:00 pm   Opportunity for Public Comment on ENT measures under consideration
4:10 pm   Pre-Rulemaking Input on the MIPS measures under consideration- ENT
4:45 pm   Opportunity for Public Comment
5:00 pm   Adjourn


Day 2  
8:30 am   Breakfast
9:00 am   Welcome and Recap of Day 1
9:15 am   Workgroup Discussion- PROMIS
10:15 am   Opportunity for Public Comment on Cancer measures under consideration
10:20 am   Pre-Rulemaking Input on the MIPS measures under consideration- Cancer
10:40 am   Opportunity for Public Comment on Spine measures under consideration
10:50 am   Pre-Rulemaking Input on the MIPS measures under consideration- Spine
11:20 am   Break
11:35 am   Opportunity for Public Comment on Anesthesia measure under consideration
11:45 am   Pre-Rulemaking Input on the MIPS measure under consideration- Anesthesia
12:00 pm   Lunch
12:30 pm   Opportunity for Public Comment on Dementia measure under consideration
12:40 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Dementia
12:50 pm   Opportunity for Public Comment on Radiology measure under consideration
1:00 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Radiology
1:15 pm   Opportunity for Public Comment on Surgery measures under consideration
1:25 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Surgery
1:35 pm   Workgroup discussion - Surgery Measures
2:05 pm   Feedback on Current MIPS Measure Set
2:45 pm   Opportunity for Public Comment
3:00 pm   Summary and Adjourn


Full Agenda

Day 1  
8:30 am   Breakfast
9:00 am   Welcome, Disclosures of Interest, Review of Meeting Objectives
Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair (substitute for Amy Moyer); John Bernot, Senior Director, NQF; Ann Hammersmith, General Counsel, NQF

9:15 am   Pre-Rulemaking Opening Remarks
Pierre Yong, CMS

9:45 am   NQF Strategic Plan
Helen Burstin, Chief Scientific Officer, NQF

10:00 am    Overview of Pre-Rulemaking Approach
Poonam Bal, Senior Project Manager, NQF; MAP will use a four step approach; Provide program overview; Review current measures; Evaluate MUCs for what they would add to the program measure set; Provide feedback on current program measure sets

10:15 am   Overview of the Medicare Shared Savings Program (MSSP)
Rabia Khan, CMS; John Bernot, CMS

10:30 am   Break
10:45 am   Opportunity for Public Comment on Smoking measure (for MSSP and MIPS) under consideration
11:00 am   Pre-Rulemaking Input on the Medicare Shared Savings Program measure under consideration
Reactors: Kevin Bowman; Robert Krughoff
  1. Adult Local Current Smoking Prevalence (MUC ID: MUC16-069)
    • Description: Percentage of adult (age 18 and older) in select county that currently smoke, defined as adults who reported having smoked at least 100 cigarettes in their lifetime and currently smoke.(The endorsed specifications of the measure are: Percentage of adult (age 18 and older) U.S. population that currently smoke.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Medicare Shared Savings Program
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses an important topic; however, it has not been tested to show that it can affect outcomes at the level of the individual clinician. The data collection is not that of structured data that can be related back to an episode of care. Additionally, an endorsed smoking screening and intervention measure already exists within the program.
      • Impact on quality of care for patients:If this measure were to be successfully tested at the individual clinician level, it could have a significant impact on death and cardiovascular disease.
    • Preliminary analysis result: Refine and resubmit


11:15 am   Feedback on Current MSSP Measure Set
12:00 pm   Lunch
12:45 pm   Overview of the Merit-Based Incentive Payment System (MIPS)
Dan Green, CMS; John Bernot, CMS

1:00 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Smoking
Reactors: Kevin Bowman; Robert Krughoff
  1. Adult Local Current Smoking Prevalence (MUC ID: MUC16-069)
    • Description: Percentage of adult (age 18 and older) in select county that currently smoke, defined as adults who reported having smoked at least 100 cigarettes in their lifetime and currently smoke.(The endorsed specifications of the measure are: Percentage of adult (age 18 and older) U.S. population that currently smoke.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 6
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses an important topic; however, it has not been tested to show that it can affect outcomes at the level of the MSSP attribution. Additionally, the data collection is not that of structured data that can be related back to an episode of care.
      • Impact on quality of care for patients:If this measure were to be successfully tested at the level specified, it could have a significant impact on death and cardiovascular disease.
    • Preliminary analysis result: Refine and resubmit


1:15 pm   Opportunity for Public Comment on HIV measures under consideration
1:25 pm   Pre-Rulemaking Input on the MIPS measure under consideration- HIV
Reactors: Scott Furney; Marci Nielson
  1. Prescription of HIV Antiretroviral Therapy (MUC ID: MUC16-072)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed HIV antiretroviral therapy for the treatment of HIV infection during the measurement year. (The endorsed specifications of the measure are: Percentage of patients, regardless of age, with a diagnosis of HIV prescribed antiretroviral therapy for the treatment of HIV infection during the measurement yearA medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Though an important clinical area, the measure does not support alignment as CMS has removed the claims based related measure, NQF#2083. Additionally, the measure has not been fully tested as an e-CQM. The testing data is in the process of being updated from the 2011 data, which should be evaluated to determine if a quality challenge remains.
      • Impact on quality of care for patients:This measure would impact the use of HIV antiretroviral therapies that are associated with reduction in morbidity and mortality.
    • Preliminary analysis result: Refine and resubmit


  2. HIV Medical Visit Frequency (MUC ID: MUC16-073)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visits. (The endorsed specifications of the measure are: Percentage of patients, regardless of age, with a diagnosis of HIV who had at least one medical visit in each 6-month period of the 24-month measurement period with a minimum of 60 days between medical visitsA medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses an important clinical area. However, it has not been fully tested as an e-CQM. The testing data is in the process of being updated from the 2011 data, which should be evaluated to determine if a quality challenge remains. If the review continues to demonstrate a quality challenge and testing is successful, it would support alignment with the claims based measure that is already part of MIPS.
      • Impact on quality of care for patients:The measure would address an important issue regarding the HIV continuum of care and would provide an additional mechanism for submitting data on this topic.
    • Preliminary analysis result: Refine and resubmit


  3. HIV Viral Suppression (MUC ID: MUC16-075)
    • Description: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement year. (The endorsed specifications of the measure are: Percentage of patients, regardless of age, with a diagnosis of HIV with a HIV viral load less than 200 copies/mL at last HIV viral load test during the measurement yearA medical visit is any visit in an outpatient/ambulatory care setting with a nurse practitioner, physician, and/or a physician assistant who provides comprehensive HIV care.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses an important clinical area. However, it has not been fully tested as an e-CQM. The testing data is in the process of being updated from the 2011 data, which should be evaluated to determine if a quality challenge remains. If the review continues to demonstrate a quality challenge and testing is successful, it would support alignment with the claims based measure that is already part of MIPS.
      • Impact on quality of care for patients:The measure would address an important issue regarding HIV viral suppression would provide an additional mechanism for submitting data on this topic.
    • Preliminary analysis result: Refine and resubmit


2:10 pm   Opportunity for Public Comment on Cardiology measures under consideration
2:20 pm   Pre-Rulemaking Input on the MIPS measures under consideration- Cardiology
Reactors: Steve Farmer; Stephanie Glier
  1. Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy (MUC ID: MUC16-074)
    • Description: Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) and a current or prior left ventricular ejection fraction (LVEF) <40% who are self-identified Black or African Americans and receiving Angiotensin-Converting Enzyme Inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) and Beta-blocker therapy who were prescribed a fixed-dose combination of hydralazine and isosorbide dinitrate seen for an office visit in the measurement period in the outpatient setting or at each hospital discharge (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure addresses both effective clinical care and potential disparities in heart failure. However, it has not been fully tested for validity.
      • Impact on quality of care for patients:This measure would track a therapy that can reduce morbidity and mortality in patients who self-identify as Black or African American.
    • Preliminary analysis result: Refine and resubmit


  2. Appropriate Use Criteria - Cardiac Electrophysiology (MUC ID: MUC16-398)
    • Description: The IAC Cardiac Electrophysiology accreditation program requires compliance to and evaluation of appropriate using published guidelines warranting the procedure. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure submission does not provide testing data that demonstrates that it influences outcomes at the individual clinician level. Additionally, the measure specifications do not outline the detail of how both "compliance to" and "evaluation of" the appropriate use criteria would be delineated. For example, the reference provided describes clinical scenarios that "should be considered in the context of the clinical situation." The current specifications do not provide enough detail as to how those would be handled by the measure. Once fully specified, complete testing would need to be performed.
      • Impact on quality of care for patients:This measure would assess adherence to appropriate use criteria as well as best practices. This could assist in effective use of resources as well as effective clinical practice.
    • Preliminary analysis result: Refine and resubmit


2:50 pm   Break
3:05 pm   Opportunity for Public Comment on Cancer measures under consideration
3:15 pm   Pre-Rulemaking Input on the MIPS measures under consideration- Cancer
Reactors: Patti Wahl; Michael Hasset
  1. Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (MUC ID: MUC16-287)
    • Description: Patients determined as having prostate cancer currently undergoing androgen deprivation therapy (ADT) or prior use of ADT who receive an initial bone density evaluation. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fulfills a gap and has been tested with multiple EHRs and registries. Recommended conditional supporting pending NQF review and endorsement.
      • Impact on quality of care for patients:This measure provides information as to whether phyiscians are appropriately conducting and documenting bone density evaluation.
    • Preliminary analysis result: Conditional support (pending NQF endorsement)


  2. Intravesical Bacillus Calmette-Guerin for NonMuscle Invasive Bladder Cancer (MUC ID: MUC16-310)
    • Description: Percentage of patients initially diagnosed with nonmuscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of initial diagnosis. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fulfills a gap and has been tested with multiple EHRs and registries. Recommended conditional supporting pending NQF review and endorsement.
      • Impact on quality of care for patients:This measure provides information on the gap area of bladder cancer measures, the 5th most common cancer diagnosis in 2016. Failure to treat the bladder cancer in a nonmuscle invasive stage can lead to invasion into the muscle layer of the bladder, requiring bladder removal and further chemotherapy and/or radiation.
    • Preliminary analysis result: Conditional support (pending NQF endorsement)


4:00 pm   Opportunity for Public Comment on ENT measures under consideration
4:10 pm   Pre-Rulemaking Input on the MIPS measures under consideration- ENT
Reactors: Terry Adirim; Winfred Wu
  1. Otitis Media with Effusion: Systemic Corticosteroids - Avoidance of Inappropriate Use (MUC ID: MUC16-268)
    • Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic corticosteroids (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:The measure received inactive endorsement with reserve status during its last endorsement review indicating the measure is topped out.
      • Impact on quality of care for patients:This measure provides information as to whether physicians are appropriately administrating systemic corticosteroids.
    • Preliminary analysis result: Do Not Support


  2. Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use (MUC ID: MUC16-269)
    • Description: Percentage of patients aged 2 months through 12 years with a diagnosis of OME who were not prescribed systemic antimicrobials (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would address the avoidance of inappropriate use of systemic antimicrobials.
      • Impact on quality of care for patients:This measure provides information as to whether physicians are appropriately administrating systemic antimicrobials.
    • Preliminary analysis result: Support


4:45 pm   Opportunity for Public Comment
5:00 pm   Adjourn


Day 2  
8:30 am   Breakfast
9:00 am   Welcome and Recap of Day 1
Bruce Bagley, Workgroup Chair; Eric Whitacre, Workgroup Chair;

9:15 am   Workgroup Discussion- PROMIS
10:15 am   Opportunity for Public Comment on Cancer measures under consideration
10:20 am   Pre-Rulemaking Input on the MIPS measures under consideration- Cancer
Reactors: Patti Wahl; Michael Hasset
  1. Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (MUC ID: MUC16-287)
    • Description: Patients determined as having prostate cancer currently undergoing androgen deprivation therapy (ADT) or prior use of ADT who receive an initial bone density evaluation. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fulfills a gap and has been tested with multiple EHRs and registries. Recommended conditional supporting pending NQF review and endorsement.
      • Impact on quality of care for patients:This measure provides information as to whether phyiscians are appropriately conducting and documenting bone density evaluation.
    • Preliminary analysis result: Conditional support (pending NQF endorsement)


  2. Intravesical Bacillus Calmette-Guerin for NonMuscle Invasive Bladder Cancer (MUC ID: MUC16-310)
    • Description: Percentage of patients initially diagnosed with nonmuscle invasive bladder cancer and who received intravesical Bacillus-Calmette-Guerin (BCG) within 6 months of initial diagnosis. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 2
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure fulfills a gap and has been tested with multiple EHRs and registries. Recommended conditional supporting pending NQF review and endorsement.
      • Impact on quality of care for patients:This measure provides information on the gap area of bladder cancer measures, the 5th most common cancer diagnosis in 2016. Failure to treat the bladder cancer in a nonmuscle invasive stage can lead to invasion into the muscle layer of the bladder, requiring bladder removal and further chemotherapy and/or radiation.
    • Preliminary analysis result: Conditional support (pending NQF endorsement)


10:40 am   Opportunity for Public Comment on Spine measures under consideration
10:50 am   Pre-Rulemaking Input on the MIPS measures under consideration- Spine
Reactors: Diane Padden; James Pacala
  1. Average change in back pain following lumbar discectomy and/or laminotomy (MUC ID: MUC16-087)
    • Description: The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add PRO to the set as well as spine surgery specific measures. The submitter does not provide specific test data. In order for full support, the submitter will need to provide data at the individual provider level.
      • Impact on quality of care for patients:Patient-reported outcomes provide valuable information for patients and consumers when selecting healthcare providers. This measure would assess the outcome of a lumbar discectomy and/or laminectomy.
    • Preliminary analysis result: Conditional support (NQF endorsement & testing supports variation at the individual provider level)


  2. Average change in back pain following lumbar fusion. (MUC ID: MUC16-088)
    • Description: The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion surgery. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add PRO to the set as well as spine surgery specific measures. The submitter does not provide specific test data. In order for full support, the submitter will need to provide data at the individual provider level.
      • Impact on quality of care for patients:Patient-reported outcomes provide valuable information for patients and consumers when selecting healthcare providers. This measure would assess the outcome of a lumbar fusion.
    • Preliminary analysis result: Conditional support (NQF endorsement & testing supports variation at the individual provider level)


  3. Average change in leg pain following lumbar discectomy and/or laminotomy (MUC ID: MUC16-089)
    • Description: The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 1
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure would add PRO to the set as well as spine surgery specific measures. The submitter does not provide specific test data. In order for full support, the submitter will need to provide data at the individual provider level.
      • Impact on quality of care for patients:Patient-reported outcomes provide valuable information for patients and consumers when selecting healthcare providers. This measure would assess the outcome of leg pain after a discectomy and/or laminectomy.
    • Preliminary analysis result: Conditional support (NQF endorsement & testing supports variation at the individual provider level)


11:20 am   Break
11:35 am   Opportunity for Public Comment on Anesthesia measure under consideration
11:45 am   Pre-Rulemaking Input on the MIPS measure under consideration- Anesthesia
Reactors: Beth Averbeck; Leslie Zun
  1. Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) (MUC ID: MUC16-312)
    • Description: Percentage of patients aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Conditional Support pending NQF endorsement.
      • Impact on quality of care for patients:This measure provides information as to whether physicians are appropriately conducting and documenting inhalational anesthetic use.
    • Preliminary analysis result: Conditional Support


12:00 pm   Lunch
12:30 pm   Opportunity for Public Comment on Dementia measure under consideration
12:40 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Dementia
Reactors: Norman Kahn; Dale Shaller
  1. Safety Concern Screening and Follow-Up for Patients with Dementia (MUC ID: MUC16-317)
    • Description: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety screening * in two domains of risk: dangerousness to self or others and environmental risks; and if screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 4
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:Conditional Support pending NQF endorsement.
      • Impact on quality of care for patients:This measure provides information as to whether physicians are appropriately screening and documenting safety concerns for persons with dementia.
    • Preliminary analysis result: Conditional Support


12:50 pm   Opportunity for Public Comment on Radiology measure under consideration
1:00 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Radiology
Reactors: David Seidenwurm; Janis Orlowski
  1. Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries (MUC ID: MUC16-343)
    • Description: Documentation of angiographic endpoints of embolization AND the documentation of embolization strategies in the presence of unilateral or bilateral absent uterine arteries. (Measure Specifications)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 0
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This measure does not appear to be tested at the Clinician level.
      • Impact on quality of care for patients:This measure provides information as to whether physicians are appropriately documenting procedural aspects of uterine artery embolization.
    • Preliminary analysis result: Refine and Resubmit


1:15 pm   Opportunity for Public Comment on Surgery measures under consideration
1:25 pm   Pre-Rulemaking Input on the MIPS measure under consideration- Surgery
Reactors: Eric Whitacre; Scott Friedman
  1. Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS) (MUC ID: MUC16-291)
    • Description: The original S-CAHPS survey, as part of the surgical patient experience battery, were designed by the American College of Surgeons (ACS) and the Surgical Quality Alliance (SQA) to address the specific needs of surgical patients. The 6 composites and 1 single-item measure were endorsed by the CAHPS Consortium in 2010 and by the National Quality Forum (NQF) in 2012. Each composite and/or grouping is used to assess a particular domain of patient experience with surgical care quality, from the patient’s perspective. This entry combined 7 measures into one MUC List entry. They are 7 separate measures (6 composite and 1 single item measure). (The endorsed specifications of the measure are: The original S-CAHPS survey, as part of the surgical patient experience battery, were designed by the American College of Surgeons (ACS) and the Surgical Quality Alliance (SQA) to address the specific needs of surgical patients. The 6 composites and 1 single-item measure were endorsed by the CAHPS Consortium in 2010 and by the National Quality Forum (NQF) in 2012. Each composite and/or grouping is used to assess a particular domain of patient experience with surgical care quality, from the patient’s perspective. This entry combined 7 measures into one MUC List entry. They are 7 separate measures (6 composite and 1 single item measure). (The endorsed specifications of the measure are: The following 6 composites and 1 single-item measure are generated from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surgical Care Survey. Each measure is used to assess a particular domain of surgical care quality from the patient’s perspective.Measure 1: Information to help you prepare for surgery (2 items)Measure 2: How well surgeon communicates with patients before surgery (4 items) Measure 3: Surgeon’s attentiveness on day of surgery (2 items) Measure 4: Information to help you recover from surgery (4 items) Measure 5: How well surgeon communicates with patients after surgery (4 items) Measure 6: Helpful, courteous, and respectful staff at surgeon’s office (2 items) Measure 7: Rating of surgeon (1 item)The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surgical Care Survey is administered to adult patients (age 18 and over) having had a major surgery as defined by CPT codes (90 day globals) within 3 to 6 months prior to the start of the survey.) (Measure Specifications; Summary of NQF Endorsement Review)
    • Programs under consideration: Merit-Based Incentive Payment System
    • Public comments received: 3
    • Preliminary analysis summary (Full Preliminary Analysis)
      • Contribution to program measure set:This patient reported outcome measure is NQF endorsed and addresses surgical care.
      • Impact on quality of care for patients:This measure provides information on the quality of the provider-patient relationship.
    • Preliminary analysis result: Support


1:35 pm   Workgroup discussion - Surgery Measures
Pierre Yong, CMS; Frank Opelka, ACS; John Bernot, NQF

2:05 pm   Feedback on Current MIPS Measure Set
2:45 pm   Opportunity for Public Comment
3:00 pm   Summary and Adjourn

Appendix A: Measure Information

Measure Index

Merit-Based Incentive Payment System

Medicare Shared Savings Program


Full Measure Information

Adult Local Current Smoking Prevalence (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-069)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Cigarette smoking is still the leading preventable cause of death and disease in the U.S. and costs the U.S. health care system nearly $170 billion in direct medical care for adults each year (CDC 2014a; HHS 2014; Xu et al. 2014). Currently more than 16 million US residents are living with a smoking-related illness (HHS 2014). Smoking harms nearly every organ in the body and has been causally linked to numerous cancers, heart disease and stroke, chronic obstructive pulmonary disease, pneumonia, other respiratory diseases, aortic aneurysm, peripheral vascular disease, cataracts and blindness, age-related macular degeneration, periodontitis, diabetes, pregnancy and reproductive complications, bone fractures, arthritis, and reduced immune function (HHS, 2014). Mortality among current smokers is two to three times that of persons who never smoked (Jha et al. 2013). Since the first Surgeon General’s Report on Smoking and Health in 1964, cigarette smoking has killed more than 20 million people in the U.S. (HHS 2014). Between 2005-2009, 87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all coronary heart disease deaths were attributable to smoking and secondhand smoke exposure (HHS, 2014), making it an essential risk factor to address to reduce both disease burden and health care costs. The toll smoking takes on health extends beyond the smokers. Since 1964, almost 2.5 million nonsmoking adults have died from heart disease and lung cancer caused by exposure to secondhand smoke, and 100,000 babies have died of sudden infant death syndrome or complications from prematurity, low birth weight, or other conditions caused by parental smoking, particularly smoking by the mother (HHS, 2014). Reducing cigarette smoking in the community can impact the health and health care costs of nonsmokers as well. CDC (Centers for Disease Control and Prevention). (2014a). CDC’s Tips from Former Smokers campaign provided outstanding return on investment. Atlanta, GA. Available at: http://www.cdc.gov/media/releases/2014/p1210-tips-roi.html. (Accessed 27 October, 2015). HHS (US Department of Health and Human Services). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. (Accessed 23 September, 2015). Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. (2014) Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine, 48(3), p.326-333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603661/ (Accessed 24 September, 2015). Jha, P. and Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 2014(370), p.60-68. Available at: http://www.nejm.org/doi/full/10.1056/nejmra1308383. (Accessed 22 October, 2015). doi: 10.1056/NEJMra1308383

Summary of NQF Endorsement Review




Appropriate Use Criteria - Cardiac Electrophysiology (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-398)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
ACCF/HRS/AHA/ASE/HFSA/SCAI/SCCT/SCMR 2013 – Appropriate Use Criteria for Implantable Cardioverter Defibrillators and Cardiac Resynchronization Therapy: A Report of the American College of Cardiology Foundation Appropriate Use Criteria Task Force, Heart Rhythm Society, American Heart Association, American Society of Echocardiography, Heart Failure Society of America, Society for Cardiovascular Angiography and Interventions, Society of Cardiovascular Computed Tomography and Society for Cardiovascular Magnetic Resonance. Endorsed by the American Geriatrics Society. Russo, A., et al, J Amer Coll Cardiol, 2013; 61(12):1318-1368. content.onlinejacc.org/article.aspx?articleid=1659563 There are many factors affecting patient care and patient management. One of the most critical to patient management is to order the right testing to diagnose the pathology, disease process or condition. There is a plethora of published data outlining the negative impact that inappropriate diagnostic testing has on the patient and the health care system on many levels. There are several components that must be in place to ensure that the imaging tests are performed safely, and ordered appropriately. However, it starts with a baseline measurement of review, evaluation documentation. Once cannot put process improvement plans in place if they are not aware that they are needed. It is only through evaluating metrics at the physician level that provides a mechanism for behavioral change and fosters a culture of quality. IAC provides a QI tool for physicians to use to review, document and benchmark the AUC in their practices. The data is secure and can be queried and benchmarked for their own purpose or against their peers. Physicians/facilities sign a Business agreement with the IAC to use the QI tool. IAC ISO 9001 – 2008 project management and ISO 2700:2013 – Information Security certified, fully compliant with HITECH and HIPAA requirements and the data is confidential. IAC medical imaging accreditation obtains and verifies many metrics of quality to ensure better patient care leading to better patient outcomes.


Average change in back pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-087)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543


Average change in back pain following lumbar fusion. (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-088)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
According to the Journal of Neurosurgery: Spine’s Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine, the assessment of functional outcomes, including pain, continues to be essential. Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Ghogawala MD, Zoher, et al. Guideline update for the performance of fusion procedures for degenerative disease of the lumbar spine. Part 2: Assessment of functional outcome following lumbar fusion. Journal of Neurosurgery: Spine. Jul 2014. DOI: 10.3171/2014.4.SPINE14258 Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543


Average change in leg pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-089)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Studies demonstrate that visual analog scales for the assessment of adult pain in general and back and leg pain specifically are valid, reliable and sensitive to change. Hawker, G. A., Mian, S., Kendzerska, T. and French, M. (2011), Measures of adult pain: Visual Analog Scale for Pain (VAS Pain), Numeric Rating Scale for Pain (NRS Pain), McGill Pain Questionnaire (MPQ), Short-Form McGill Pain Questionnaire (SF-MPQ), Chronic Pain Grade Scale (CPGS), Short Form-36 Bodily Pain Scale (SF-36 BPS), and Measure of Intermittent and Constant Osteoarthritis Pain (ICOAP). Arthritis Care & Research, 63: S240–S252. doi: 10.1002/acr.20543


Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-287)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Androgen suppression as a treatment for prostate cancer can cause osteoporosis. (Gleason et al. General & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness). Men undergoing prolonged androgen deprivation therapy (ADT) incur bone loss at a rate higher than menopausal women. (AUA. Business Cases in Urology: CRPC). In preserving bone health, the goal is to prevent or treat osteopenia /osteoporosis for the patient on ADT and to prevent or delay skeletal related events (SRE). The National Osteoporosis Foundation recommendations including a baseline assessment of bone density with a DEXA scan and daily calcium and Vitamin D supplementation. (Gaylis et al. Compliance with Evidence Based Bone Health Management in Men on chronic ADT: Opportunities for Improvement). The DEXA scan is the gold standard for bone density screening. Men at risk for adverse bone consequences from chronic ADT do not always receive care according to evidence based guidelines. These findings call for improved processes that standardize evidence based practice including baseline and follow up bone density assessment. (Gaylis et al).


Febrile Neutropenia Risk Assessment Prior to Chemotherapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-151)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Seven articles published from 2006 to 2016 provide insights into the benefits of FN risk assessment: Donohue (2006): Among patients receiving chemotherapy, the rates CSF prophylaxis were higher in those who were managed with a Risk Assessment Tool, than those in a “control group” that received care without use of the tool in an earlier time period (72% versus 28%, respectively, p<0.001). Conversely, the rates of adverse outcomes were higher in the control group than in the Risk Assessment Tool Group, but not statistically significant: febrile neutropenia (14% versus 11%, respectively), treatment with IV antibiotics (28% versus 14%), hospitalizations secondary to febrile neutropenia (16% versus 11%), and chemotherapy dose reductions (10% versus 3%). Doyle (2006): In a pre-post intervention study of patients initiating chemotherapy or a new regimen, use of tool for assessing patient risk of FN lowered the rate of FN-related hospitalization by 78%, from 9.7% among 155 patients in FY04 to 2.1% among 189 patients in FY05 (P = 0.003). Miller (2006): In a study of an intervention with a computer-based risk assessment tool (CBRAT), the rate of documenting performance of an FN risk assessment was 13% before use of the CBRAT and 100% after its introduction (p<0.001). O’Brien et al. (2014): An intervention study in a hospital-based oncology unit used an FN risk assessment tool to decide which patients receiving chemotherapy to treat with CSF. Comparing the time periods before (N=233 patients) and after (N=226 patients) the tool was used, the incidence of FN was reduced by 52% (p=0.02). Krzemieniecki et al. (2014): A total of 1,347 patients with solid tumors were eligible for the study based on being scheduled for “myelotoxic” chemotherapy and having an “investigator-assessed FN risk” of = 20%. The study found 45-80% of these patients, depending on the tumor site, did not receive G-CSF that was indicated by results of the FN risk assessment by the investigator and guideline recommendations. Freyer et al. (2015): In a study of 165 physicians and 944 patients, each physician rated FN risk for their own patients using factors they selected. Only 82% of patients with an FN risk at or above 20% based on the physician-assessed FN risk were scheduled to receive CSF indicating almost one of five patients would not receive G-CSF PP even though the patient’s risk was rated higher than the threshold of 20%. Mäenpää et al. (2016): In a study of 690 breast cancer patients (stages I-III) receiving chemotherapy, a higher proportion of those with a high-risk regimen were given G-CSF primary prophylaxis than those with a lower-risk regimen (48% versus 22%). However, these results indicate that less than half of patients on a high-risk regimen received appropriate treatment with G-CSF. References: Donohue, R. (2006). Development and implementation of a risk assessment tool for chemotherapy-induced neutropenia. Oncol Nurs Forum, 33(2), 347-352. Doyle, A. M. (2006). Prechemotherapy assessment of neutropenic risk. Oncology (Williston Park), 20(10 Suppl Nurse Ed), 32-39; discussion 39-40. Miller, K. (2010). Using a computer-based risk assessment tool to identify risk for chemotherapy-induced febrile neutropenia. Clin J Oncol Nurs, 14(1), 87-91. O'Brien, C., Dempsey, O., & Kennedy, M. J. (2014). Febrile neutropenia risk assessment tool: improving clinical outcomes for oncology patients. Eur J Oncol Nurs, 18(2), 167-174. Krzemieniecki, K., Sevelda, P., Erdkamp, F., Smakal, M., Schwenkglenks, M., Puertas, J., et al. (2014). Neutropenia management and granulocyte colony-stimulating factor use in patients with solid tumours receiving myelotoxic chemotherapy--findings from clinical practice. Support Care Cancer, 22(3), 667-677. Freyer, G., Kalinka-Warzocha, E., Syrigos, K., Marinca, M., Tonini, G., Ng, S. L., et al. (2015). Attitudes of physicians toward assessing risk and using granulocyte colony-stimulating factor as primary prophylaxis in patients receiving chemotherapy associated with an intermediate risk of febrile neutropenia. Med Oncol, 32(10), 236. Maenpaa, J., Varthalitis, I., Erdkamp, F., Trojan, A., Krzemieniecki, K., Lindman, H., et al. (2016). The use of granulocyte colony stimulating factor (G-CSF) and management of chemotherapy delivery during adjuvant treatment for early-stage breast cancer-Further observations from the IMPACT solid study. Breast, 25, 27-33.

Summary of NQF Endorsement Review




Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-074)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The African-American Heart Failure Trial (A-HeFT) first published in 2004 demonstrated that there is significant benefit for African American patients who receive the fixed-dose combination therapy of hydralazine and isosorbide dinitrate. A-HeFT built on the findings from the two Vasodilator-Heart Failure Trials (V-HeFT). A-HeFT, which was ended early due to the mortality rates in the placebo population, demonstrated a 43% reduction in mortality, a 33% decrease in initial hospitalizations, and a 50% improvement in patient-reported quality of life (Taylor, 2004; Sharma, 2014). These results clearly demonstrate that the fixed-dose combination therapy significantly improves patient morbidity, mortality and quality of life in this clinical cohort. There is no substitute for the fixed-dose combination therapy. Even with this strong evidence of unprecedented efficacy and cost-effectiveness, research shows that more than 85% of African American patients are not receiving the quality of care that this therapy affords, constituting a significant gap in care quality (Dickson, 2015). The underuse of the fixed-dose combination of hydralazine plus isosorbide dinitrate in African Americans with severe heart failure is a health care and health quality disparity that exposes these patients to an elevated risk for mortality and hospitalization, and compromises efforts to contain the escalating system costs by preventing or reducing unnecessary hospitalizations and readmissions. Based upon research on the mortality benefit of the fixed-dose combination (Fonarow, 2011), the National Minority Quality Forum estimates that 51,542 (27%) of the 189,891 African American Medicare beneficiaries who were being treated for heart failure and received their prescription drugs under Part D should have been treated with the fixed-dose combination; but only 2,377 (5%) had at least one prescription (30-day supply) of the therapy. Further, the National Minority Quality Forum estimates that between 2008 and 2010, only 3% of the eligible patient cohort in Medicare received the therapy. Given the documented number to treat to receive the mortality benefit (21), it can be estimated that from 2007 through 2010, 20,000 African American Medicare beneficiaries died as a result of the failure to receive quality care as defined by evidence-based guidelines. The proven benefits to this patient population are significant and there is a clear opportunity for improvement. Failure to do so constitutes a failure to provide quality and cost-effective care. As with other diagnoses and available therapies, we anticipate that the evidence supporting this measure will continue to evolve. For example, research continues to explore if the fixed-dose combination of hydralazine and isosorbide dinitrate is linked to a particular genetic polymorphism (NIH funded Genomic Response Analysis of Heart Failure Therapy in African Americans). References Dickson VV, Knafl GJ, Wald J, Riegel B. Racial differences in clinical treatment and self-care behaviors of adults with chronic heart failure. J Am Heart Assoc. 2015;4:1-13. Fonarow GC, Yancy CW, Hernandez AF, Peterson ED, Spertus JA, Heidenreich PA. Potential impact of optimal implementation of evidence-based heart failure therapies on mortality. Am Heart J. 2011;161:1024-1030. Sharma A, Colvin-Adams M, Yancy CW. Heart failure in African Americans: disparities can be overcome. Cleve Clin J Med. 2014;81:301-11. Taylor AL, Ziesche S, Yancy C, et al. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. N Engl J Med 2004; 351:2049–57.


HIV Medical Visit Frequency (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-073)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Early linkage to and long-term retention in HIV care leads to better health outcomes. Linkage to HIV medical care shortly after HIV diagnosis and continuous care thereafter provide opportunities for risk reduction counseling, initiation of treatment, and other strategies that improve individual health and prevent onward transmission of infection (1-6). Delayed linkage and poor retention in care are associated with delayed receipt of antiretroviral treatment, higher rate of virologic failure, and increased morbidity and mortality (5,7). Poor retention in care during the first year of outpatient medical care is associated with delayed or failed receipt of antiretroviral therapy, delayed time to virologic suppression and greater cumulative HIV burden, increased sexual risk transmission behaviors, increased risk of long-term adverse clinical events, and low adherence to antiretroviral therapy (1,5,7,9). Early retention in HIV care has been found to be associated with time to viral load suppression and 2-year cumulative viral load burden among patients newly initiating HIV medical care (8). References: 1. Giordano TP, Gifford AL, White AC Jr, Suarez-Almazor ME, Rabeneck L, Hartman C, et al. Retention in care: a challenge to survival with HIV infection. Clin Infect Dis. 2007; 44:1493-9. 2. Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, Kumarasamy N, et al.; HPTN 052 Study Team. Prevention of HIV -1 infection with early antiretroviral therapy. N Engl J Med. 2011; 365:493-505. 3. Giordano TP, White AC Jr, Sajja P, Graviss EA, Arduino RC, Adu-Oppong A, et al. Factors associated with the use of highly active antiretroviral therapy in patients newly entering care in an urban clinic. J Acquir Immune Defic Syndr. 2003; 32:399-405. 4. Lucas GM, Chaisson RE, Moore RD. Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions. Ann Intern Med. 1999; 131:81-7. 5. Metsch LR, Pereyra M, Messinger S, Del Rio C, Strathdee SA, Anderson-Mahoney P, et al.; Antiretroviral Treatment and Access Study (ART AS) Study Group. HIV transmission risk behaviors among HIV -infected persons who are successfully linked to care. Clin Infect Dis. 2008; 47:577-84. 6. Montaner JS, Lima VD, Barrios R, Yip B, Wood E, Kerr T, et al. Association of highly active antiretroviral therapy coverage, population viral load, and yearly new HIV diagnoses in British Columbia, Canada: a population-based study. Lancet. 2010; 376:532- 9. 7. Ulett KB, Willig JH, Lin HY, Routman JS, Abrams S, Allison J, Chatham A, Raper JL, Saag MS, Mugavero MJ. The therapeutic implications of timely linkage and early retention in HIV care. AIDS Patient Care STDS. 2009 Jan; 23(1):41-9. 8. Mugavero MJ, Amico KR, Westfall AO, Crane HM, Zinski A, Willig JH, Dombrowski JC, Norton WE, Raper JL, Kitahata MM, Saag MS. Early retention in HIV care and viral load suppression: implications for a test and treat approach to HIV prevention. J Acquir Immune Defic Syndr. 2012 Jan 1; 59(1):86-93. 9. Mugavero MJ, Lin HY, Willig JH, Westfall AO, Ulett KB, Routman JS, Abroms S, Raper JL, Saag MS, Allison JJ. Missed visits and mortality among patients establishing initial outpatient HIV treatment. Clin Infect Dis. 2009 Jan 15;48(2):248-56.

Summary of NQF Endorsement Review




HIV Viral Suppression (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-075)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Sustained viral load suppression is directly related to reduction in disease progression and to reduction in potential for transmission of infection. Among persons in care, sustained viral load suppression represents the cumulative effect of prescribed therapy, ongoing monitoring, and patient adherence. The proposed measure will direct providers’ attention and quality improvement efforts towards this important outcome.

Summary of NQF Endorsement Review




Identification of Major Co-Morbid Medical Conditions (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-279)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
ASA class is a reliable independent predictor of medical complications and mortality following surgery. Hackett N; De Oliveira G; Jain U; Kim J. World J Surg. 2015 May 8th A New method of classifying prognostic comorbidity in longitudinal studies: development and validation Charlson, M; Pompei, P; Ales, K; MacKenzie, C. J Chron Dis. 198; 40(5):373-383. Association of comorbidities with postoperative in-hospital mortality: a retrospective cohort study Kork, F; Balzer, F, et al. Medicine 2015; 94(8): 576


Intraoperative Surgical Debriefing (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-316)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Cumin D, Skilton C, Weller J. Information transfer in multidisciplinary operating room teams: a simulation-based observational study. BMJ Qual Saf. 2016 doi: 10.1136/bmjqs-2015-005130 WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives. World Health Organization (WHO). 2009. http://www.who.int/patientsafety/safesurgery/tools_resources/9789241598552/en/ Wyrick DL, Smith SD, Dassinger MS. Implementation of the World Health Organization checklist and debriefing improves accuracy of surgical wound class documentation. Am J Surg. 2015; 210(6):1051-4 Porta CR, Foster A, Causey MW, Cordier P, et al. Operating room efficiency improvement after implementation of a postoperative team assessment. J Surg Res. 2013; 180(1):15-20 Papaspyros SC, Javangula KC, Alduri RK, O’Regan DJ. Briefing and debriefing in the cardiac operating room: Analysis of impact on theatre team attitude and patient safety. Interact Cardiovasc Thorac Surg. 2010;10(1)43-7 Berenholtz SM, Schumacher K, Hayanga AJ, Simon M, et al. Implementing standardized operating room briefings and debriefings at a large regional medical center. Jt Comm J Qual Patient Saf 2009; 35(8):391-7 Bethune R, Sasirekha G, Sahu A, Cawthorn S, et al. Use of briefings and debriefings as a tool in improving team work, efficiency, and communication in the operating theatre. Postgrad Med J. 2011; 87(1027):331-4


Intraoperative Timeout Safety Checklist (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-280)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Van Klei WA, Hoff RG, et al. Effects of the introduction of the WHO "Surgical Safety Checklist" on in-hospital mortality: a cohort study. Annals of Surgery. 2012 Jan;255(1):44-9. Mayer EK, Sevdais N, et al. Surgical Checklist Implementation Project: The Impact of Variable WHO Checklist Compliance on Risk-adjusted Clinical Outcomes After National Implementation: A Longitudinal Study. Annals of Surgery. 2016 Jan;263(1):58-63. Paull DE, Mazzia LM, et al. Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program. American Journal of Surgery. 2010 Nov;200(5):620-3.


Intravesical Bacillus Calmette-Guerin for NonMuscle Invasive Bladder Cancer (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-310)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
There are no bladder cancer measures, yet it is the 5th common cancer diagnosis in 2016. Failure to treat the bladder cancer in a nonmuscle invasive stage can lead to invasion into the muscle layer of the bladder, requiring bladder removal and further chemotherapy and/or radiation.


Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-269)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic antimicrobials have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. STATEMENT 8b. ANTIBIOTICS: Clinicians should recommend against using systemic antibiotics for treating OME. Strong recommendation based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016) Data detailing the prescription of systemic antimicrobials for otitis media with effusion in children is limited. However, in a small 2008 study by Patel et al, 7% of physicians in an otolaryngology practice prescribed systemic antimicrobials for pediatric patients presenting with OME [1]. In a 2014 study involving 5 focus groups of parents, most parents believed that antibiotics were needed to treat otitis media and expressed frustration with a “watchful waiting” approach [2]. In a 2013 study by Forrest et al evaluating clinical decision support for management of OME, 78%-93% of physicians employed a “watchful waiting” strategy to manage OME [3]. 1. Patel MM, Eisenberg L, Witsell D, Schulz KA. Assessment of acute otitis externa and otitis media with effusion performance measures in otolaryngology practices. Otolaryngol Head Neck Surg. 2008;139:490-494. 2. Finkelstein JA, Dutta-Linn M, Meyer R, Goldman R. Childhood infections, antibiotics, and resistance: what are parents saying now? Clin Pediatr (Phila). 2014;53(2):145-150. Doi:10.1177/0009922813505902. 3. Forrest CB, Fiks AG, Bailey LC, et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics. 2013;131(4):e1071-e1081.

Summary of NQF Endorsement Review




Otitis Media with Effusion: Systemic Corticosteroids - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-268)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
OME usually resolves spontaneously with indications for therapy only if the condition is persistent and clinically significant benefits can be achieved. Systemic steroids have no proven long-term effectiveness and have potential adverse effects. The purpose of the corresponding guideline statement is to reduce ineffective and potentially harmful medical interventions in OME when there is no long-term benefit to be gained in the vast majority of cases. Medications have long been used to treat OME, with the dual goals of improving QOL and avoiding more invasive surgical interventions. Both the 1994 guidelines and the 2004 guidelines determined that the weight of evidence did not support the routine use of steroids (either oral or intranasal), antimicrobials, antihistamines, or decongestants as therapy for OME. STATEMENT 8a. STEROIDS: Clinicians should recommend against using intranasal steroids or systemic steroids for treating OME. Strong recommendation against based on systematic review of RCTs and preponderance of harm over benefit. Clinical Practice Guideline: Otitis Media with Effusion (Update). Rosenfeld RM et al. Otolaryngol Head Neck Surg. (2016) Data detailing the prescription of systemic corticosteroids for otitis media with effusion in children is limited. However, in a small 2008 study by Patel et al, 10% of physicians in an otolaryngology practice prescribed systemic corticosteroids for pediatric patients presenting with OME [1]. In a 2013 study by Forrest et al evaluating clinical decision support for management of OME, 78%-93% of physicians employed a “watchful waiting” strategy to manage OME [2]. 1. Patel MM, Eisenberg L, Witsell D, Schulz KA. Assessment of acute otitis externa and otitis media with effusion performance measures in otolaryngology practices. Otolaryngol Head Neck Surg. 2008;139:490-494. 2. Forrest CB, Fiks AG, Bailey LC, et al. Improving adherence to otitis media guidelines with clinical decision support and physician feedback. Pediatrics. 2013;131(4):e1071-e1081.

Summary of NQF Endorsement Review




Participation in a National Risk-adjusted Outcomes Surgical Registry (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-286)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
The American college of surgeons national surgical quality improvement program: achieving better and safer surgery. Ko, CY; Hall BL; Hart AJ; Cohen ME; Hoyt, DB. Jt. Comm J Qual Patient Saf. 2015; 41(5) 199 Adverse outcomes in surgical patients: implementation of a nationwide reporting system. Marang-van P; Stadlander M; Kievit J. Qual Saf Health Care 2006 15(5): 320-4. The future of quality measurement in the United States. Yi F. Clin Colon Rectal Surg 2014 27(1) 32-8.


Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-291)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Surgeries are frequently performed procedures that affect large numbers of patients in the population, have high resource use, and poor quality can have serious consequences for patients, including death. Therefore, improving the quality of surgical care is of paramount importance to patients and the healthcare system alike. In a study based on the HCUP 2007 data, in 28 states that were evaluated, there were nearly 5,600 ambulatory surgery (AS) visits per 100,000 in the population and almost 4,100 inpatient surgical visits per 100,000. The mean charge for ambulatory surgery is about $6,100 and for inpatient surgery is about $39,900. The aggregate charge across the 28 states for ambulatory surgery was about $55.6 billion and the total inpatient charges were about $259 billion. Patient experience measures as indicators of quality for health plans are linked to health plan disenrollment. The mean voluntary disenrollment rate among Medicare managed care enrollees is four times higher for plans in the lowest 10 percent of overall CAHPS Health Plan survey ratings than for those in the highest 10 percent. At the provider level, patients who reported the poorest-quality relationships with their physicians are three times more likely to voluntarily leave the physician’s practice than patients with the highest-quality relationships. The quality of the provider-patient relationship as evident in good patient experience scores correlates with lower medical malpractice risk. Although average patient experience scores can mask variations within a provider’s scores, the minimum score a provider receives correlates with the likelihood of being implicated in a medical malpractice suit. Each drop in minimum overall score along a five-step scale of “very good” to “very poor” corresponds to a 21.7 percent increase in the likelihood of being named in a suit. Forty-six percent of malpractice risk is attributed to physician specific characteristics, including patient experience. Efforts to improve patient experience also result in greater employee satisfaction, reducing turnover. Improving patients’ experiences requires improving work processes and systems that enable clinicians and staff to provide effective care. A focused endeavor to improve patients’ experiences at one hospital also resulted in a 4.7 percent reduction in employee turnover. Similarly, nurse satisfaction is strongly positively correlated with patients’ intent to return to or to recommend the hospital.

Summary of NQF Endorsement Review




Patient Frailty Evaluation (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-278)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Fried LP, Tangen CM, Walston J, Newman AB, Hirsch C, Gottdiener J, Seeman T, Tracy R, Kop WJ, Burke G, McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype. J Gerontol A Biol Sci Med Sci. 2001 Mar;56(3):M146-56. Makary MA, Segev DL, Pronovost PJ, Syin D, Bandeen-Roche K, Patel P, Takenaga R, Devgan L, Holzmueller CG, Tian J, Fried LP. Frailty as a predictor of surgical outcomes in older patients. J Am Coll Surg. 2010 Jun;210(6):901-8.. Theou O, Brothers TD, Peña FG, Mitnitski A, Rockwood K. Identifying common characteristics of frailty across seven scales. J Am Geriatr Soc. 2014 May;62(5):901-6. Malmstrom TK, Miller DK, Morley JE. A comparison of four frailty models. J Am Geriatr Soc. 2014 Apr;62(4):721-6. Hewitt J, Moug SJ, Middleton M, Chakrabarti M, Stechman MJ, McCarthy K; Older Persons Surgical Outcomes Collaboration. Prevalence of frailty and its association with mortality in general surgery. Am J Surg. 2015 Feb;209(2):254-9. Collard RM, Boter H, Schoevers RA, Oude Voshaar RC. Prevalence of frailty in community- dwelling older persons: a systematic review. J Am Geriatr Soc. 2012 Aug;60(8):1487-92. Example of FRAIL scale, from: Morley JE, Malmstrom TK, Miller DK. A simple frailty questionnaire (FRAIL) predicts outcomes in middle aged African Americans. J Nutr Health Aging. 2012 Jul;16(7):601-8.


Patient-Centered Surgical Risk Assessment and Communication (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-293)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Preoperative risk assessment and communication between surgeons and patients is critical for effective informed consent and shared decision making in surgical care. Shared decision-making is considered an integral component of patient-centered care, especially for preference-sensitive issues. Evidence suggests that there is room for improving communication and the informed consent/shared decision-making processes between physicians and patients. Use of a risk calculator helps improve the quality of the informed consent/shared decision-making process by providing a personalized, customized, empirically-based estimate of a patient’s risk of post-operative complications. Moreover, evidence suggests that sharing numeric estimates of patient-specific risk may enhance patient trust in providers.


Perioperative Composite (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-282)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
WHO guidelines for safe surgery: safe surgery saves lives. World Health Organization. 2009 Hospital Conditions of Participation (CoPs). Centers for Medicare and Medicaid Services. February 2008. The Universal Protocol for Preventing Wrong Site, Wrong Procedure, and Wrong Person Surgery. The Joint Commission. November 26, 21012. Haugen et al. Effect of the World Health Organization Checklist on Patient Outcomes: A Stepped Wedge Cluster Randomized Controlled Trial. Ann Surg; epub May 2014. Askarian M, et al. Effect of surgical safety checklists on postoperative morbidity and mortality rates, Shiraz, Faghihy Hospital, a 1-year study. Qual Manag Health Care 2011; 20: 293–7. de Vries EN, et al. Effect of a comprehensive surgical safety system on patient outcomes. New England Journal of Medicine 2010; 363: 1928–37.


Post-Discharge Review of Patient Goals of Care (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-345)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Steffens NM, Tucholka JL, Nabozny MK, Schmick AE, et al. Engaging patients, health care professionals, and community members to improve preoperative decision making for older adults facing high-risk surgery. JAMA Surg. 2016. doi: 10.1001/jamasurg.2016.1308 Kelly KN, Noyes K, Dolan J, Fleming F, et al. Patient perspective on care transitions after colorectal surgery. J Surg Res. 2016; 203(1):103-12 Gussous Y, Than K, Mummameni P, Smith J, et al. Appropriate use of limited interventions vs extensive surgery in the elderly patient with spinal disorders. Neurosurgery. 2015; 77 suppl 4:S142-63 Kim Y, Winner M, Page A, Tisnado DM, et al. Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer. Cancer 2015; 121(20):3564-73 Paul Olson TJ, Brasel JH, Redmann AJ, Alexander GC, et al. Surgeon-reported conflict with intensivist about postoperative goals of care. JAMA Surg. 2013. 148(1):29-35.


Postoperative Care Coordination and Follow-up with Primary/Referring Provider (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-281)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Care Coordination. May 2015. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/coordination/index.html. May 2015.


Postoperative Care Plan (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-283)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Kaufmnan J, et al. A handoff protocol from the cardiovascular operating room to cardiac ICU is associated with improvements in care beyond the immediate postoperative period. Joint Commission Journal on Quality and Patient Safety. 2013 Jul;39(7):306-11. McElroy LM, Collins KM, et al. Operating room to intensive care unit handoffs and the risks of patient harm. Surgery. 2015 Sep;158(3):588-94. Symons NR, Almoudaris AM, Nagpal K, Vincent CA, Moorthy K. An observational study of the frequency, severity, and etiology of failures in postoperative care after major elective general surgery. Annals of Surgery. 2013 Jan;257(1):1-5.


Postoperative Plan Communication with Patient and Family (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-277)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Kelly KN, Noyes K, et al. Patient perspective on care transitions after colorectal surgery. Journal of Surgical Research. 2016 Jun 1;203(1):103-12. Schmocker RK, Holden SE, et al. Association of Patient-Reported Readiness for Discharge and Hospital Consumer Assessment of Health Care Providers and Systems Patient Satisfaction Scores: A Retrospective Analysis. Journal of the American College of Surgeons. 2015 Dec;221(6):1073-82. McMurray A, Johnson P, Wallis M, Patterson E, Griffiths S. General surgical patients' perspectives of the adequacy and appropriateness of discharge planning to facilitate health decision-making at home. Journal of Clinical Nursing. 2007 Sep;16(9):1602-9.


Postoperative Review of Patient Goals of Care (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-284)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Steffens NM, Tucholka JL, Nabozny MK, Schmick AE, et al. Engaging patients, health care professionals, and community members to improve preoperative decision making for older adults facing high-risk surgery. JAMA Surg. 2016. doi: 10.1001/jamasurg.2016.1308 Kelly KN, Noyes K, Dolan J, Fleming F, et al. Patient perspective on care transitions after colorectal surgery. J Surg Res. 2016; 203(1):103-12 Gussous Y, Than K, Mummameni P, Smith J, et al. Appropriate use of limited interventions vs extensive surgery in the elderly patient with spinal disorders. Neurosurgery. 2015; 77 suppl 4:S142-63 Kim Y, Winner M, Page A, Tisnado DM, et al. Patient perceptions regarding the likelihood of cure after surgical resection of lung and colorectal cancer. Cancer 2015; 121(20):3564-73 Paul Olson TJ, Brasel JH, Redmann AJ, Alexander GC, et al. Surgeon-reported conflict with intensivist about postoperative goals of care. JAMA Surg. 2013. 148(1):29-35.


Preoperative Key Medications Review for Anticoagulation Medication (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-276)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e326S. Perioperative management of patients receiving anticoagulants. Gregory YH LIP and James D Douketis. UpToDate May 2015. Douketis JD. Perioperative management of patients who are receiving warfarin therapy: an evidence-based and practical approach. Blood 2011; 117:5044. Gallego P, Apostolakis S, Lip GY. Bridging evidence-based practice and practice-based evidence in periprocedural anticoagulation. Circulation 2012; 126:1573. Kearon C, Hirsh J. Management of anticoagulation before and after elective surgery. N Engl J Med 1997; 336:1506.


Prescription of HIV Antiretroviral Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-072)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
HIV Antiretroviral therapy reduces HIV-associated morbidity and mortality by maximally inhibiting HIV replication (as defined by achieving and maintaining plasma HIV RNA (viral load) below levels detectable by commercially available assays). Emerging evidence also suggests that additional benefits of ART-induced viral load suppression include a reduction in HIV-associated inflammation and possibly its associated complications.

Summary of NQF Endorsement Review




Preventative Care and Screening: Tobacco Screening and Cessation Intervention (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-289)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Effects of a perioperative smoking cessation intervention on postoperative complications. Lindstrom D; Azodi OS et al. Annals of Surgery 2008; 248(5); 739-45. The effectiveness of a perioperative smoking cessation program: A randomized clinical trial Lee SM; Landry J; Jones PM et al. Anesthesia & Analgesia 2013; 177(3); 605-13. U.S. Department of Health and Human Services. Public Health Service, 2008 Interventions for preoperative smoking cessation Thomsen T, Villebro N, Moller AM. Cochrane Database Systematic Review. 2014 • Strength of Evidence = A o All patients should be asked if they use tobacco and should have their tobacco use status documented on a regular basis. Evidence has shown that clinic screening systems, such as expanding the vital signs to include tobacco use status, significantly increase rates of clinical intervention. o All physicians should strongly advise every patient who smokes to quit because evidence suggests that physicians’ advice to quit smoking increases abstinence rates. o The combination of counseling and medication is more effective for smoking cessation than either medication or counseling alone. Therefore, both counseling and medication should be provided to patients trying to quit smoking.


Prevention of Post-Operative Vomiting (POV) - Combination Therapy (Pediatrics) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-312)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is highly dissatisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk factors for PONV; demonstrated effective prophylactic regimes based on these risk factors; and demonstrated high variability in this outcome across individual centers and providers (Kranke & Eberhart, 2011; Singla et al., 2010). Further, a number of papers have shown that performance can be assessed at the level of individual providers — the outcome is common enough that sufficient power exists to assess variability and improvement at this level (Dzwonczyk et al., 2012). A separate measure is needed for pediatric patients because the risk factors and recommended prophylaxis are different from adults. Dzwonczyk R, Weaver TE, Puente EG, Bergese SD. Postoperative nausea and vomiting prophylaxis from an economic point of view. Am J Ther. 2012 Jan;19(1):11-5. Kranke P, Eberhart LH. Possibilities and limitations in the pharmacological management of postoperative nausea and vomiting. Eur J Anaesthesiol. 2011 Nov;28(11):758-65. Singla NK, Singla SK, Chung F, Kutsogiannis DJ, Blackburn L, Lane SR, Levin J, Johnson B, Pergolizzi JV Jr. Phase II study to evaluate the safety and efficacy of the oral neurokinin-1 receptor antagonist casopitant (GW679769) administered with ondansetron for the prevention of postoperative and postdischarge nausea and vomiting in high-risk patients. Anesthesiology. 2010;113(1):74-82.


Resumption Protocol (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-292)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Henderson PW, Landford W, Gardenier J, Otterburn DM, et al. A simple, visually oriented communication system to improve postoperative care following microvascular free tissue transfer: development, results and implications. J Reconstr Microsurg. 2016; 32(6): 464-9 Salzwedel C, Mai V, Punke MA, Kluge S, et al. The effect of a checklist on the quality of patient handover from the operating room to the intensive care unit: A randomized controlled trial. J Crit Care. 2016;32:170-4 Streeton A, Bisbey C, O’Neill C, Allen D, et al. Improving nurse-physician teamwork: a multidisciplinary collaboration. Medsurg Nurs. 2016; 25(1):31-4 Agarwal HS, Saville BR, Slayton JM, Donahue DS, et al. Standardized postoperative handover process improves outcomes in the intensive care unit: a model for operational sustainability and improved team performance. Crit Care Med. 2012; 40(7):2109-15 Segall N, Bonifacio AS, Schroeder RA, Barbeito A, et al. Can we make postoperative patient handovers safer? A systematic review of the literature. Anesth Analg. Jul; 115(1):102-15 Joy BF, Elliott E, Hardy C, Sullivan C, et al. Standardized multidisciplinary protocol improves handover of cardiac surgery patients to the intensive care unit. Pediatr Crit Care Med. 2011; 12(3):304-8


Safety Concern Screening and Follow-Up for Patients with Dementia (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-317)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse (Category I). Important safety issues in the management of patients with dementia include interventions to decrease the hazards of wandering and recommendations concerning activities such as cooking, driving, hunting, and the operation of hazardous equipment. Caregivers should be referred to available books [and other materials] that provide advice and guidance about maximizing the safety of the environment for patients with dementia…As patients become more impaired, they are likely to require more supervision to remain safe, and safety issues should be addressed as part of every evaluation. Families should be advised about the possibility of accidents due to forgetfulness (e.g., fires while cooking), of difficulties coping with household emergencies, and of the possibility of wandering. Family members should also be advised to determine whether the patient is handling finances appropriately and to consider taking over the paying of bills and other responsibilities. At this stage of the disease [i.e., moderately impaired patients], nearly all patients should not drive. (1) For mild to moderate Alzheimer's disease Assess for safety risks (e.g., driving, financial management, medication management, home safety risks that could arise from cooking or smoking, potentially dangerous behaviors such as wandering) (2) 1. American Psychiatric Association (APA). Practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Arlington (VA): American Psychiatric Association (APA). October 2007 85 p. 2. Chertkow H. Diagnosis and treatment of dementia: introduction. Introducing a series based on the Third Canadian Consensus Conference on the Diagnosis and Treatment of Dementia. CMAJ. 2008;178:316-321.


Surgical Plan and Goals of Care (Preoperative Phase) (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-288)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Fried TR, Bradley EH, Towle VR, Allore H. Understanding the treatment preferences of seriously ill patients. N Engl J Med. 2002 Apr 4;346(14):1061-6. Kaldjian LC, Curtis AE, Shinkunas LA, Cannon KT. Goals of care toward the end of life: a structured literature review. Am J Hosp Palliat Care. 2008 Dec-2009 Jan;25(6):501-11. Reuben DB. Medical care for the final years of life: "When you're 83, it's not going to be 20 years". JAMA. 2009 Dec 23;302(24):2686-94. Oresanya LB, Lyons WL, Finlayson E. Preoperative assessment of the older patient: a narrative review. JAMA. 2014 May;311(20):2110-20.


Unplanned Hospital Readmission within 30 Days of Principal Procedure (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-285)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
A modified-Delphi methodology using an expert panel of surgeons who are Directors of the American Board of Surgery identified this to be a critical outcome for this surgical procedure (Surgeon Specific Registry Report on Project for ABS MOC Part IV. Unpublished study by the American College of Surgeons in conjunction with the American Board of Surgery, 2011).


Uterine artery embolization technique: Documentation of angiographic endpoints and interrogation of ovarian arteries (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-343)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
This measure ensures documentation of two important procedural aspects of uterine artery embolization, which are known to be associated with treatment efficacy: (1) appropriate embolization endpoints achieved and (2) delineation of all uterine arterial supply with embolization where possible. Inadequate embolization alone is a known cause of treatment failure1. The ovarian arteries often provide an alternate route of arterial supply to the uterus when the uterine artery is occluded or absent; however routine aortography is not recommended when conventional uterine artery anatomy is present2. 1. Dariushnia SR et al. Quality Improvement Guidelines for Uterine Artery Embolization for Symptomatic leiomyomata. JVIR 2014; 25:1737-1747. 2. White AM et al. Patient radiation exposure during uterine fibroid embolization and the dose attributable to aortography. JVIR 2007; 18:573-576.


Adult Local Current Smoking Prevalence (Program: Medicare Shared Savings Program; MUC ID: MUC16-069)

Measure Specifications

Preliminary Analysis of Measure

Rationale for measure provided by HHS
Cigarette smoking is still the leading preventable cause of death and disease in the U.S. and costs the U.S. health care system nearly $170 billion in direct medical care for adults each year (CDC 2014a; HHS 2014; Xu et al. 2014). Currently more than 16 million US residents are living with a smoking-related illness (HHS 2014). Smoking harms nearly every organ in the body and has been causally linked to numerous cancers, heart disease and stroke, chronic obstructive pulmonary disease, pneumonia, other respiratory diseases, aortic aneurysm, peripheral vascular disease, cataracts and blindness, age-related macular degeneration, periodontitis, diabetes, pregnancy and reproductive complications, bone fractures, arthritis, and reduced immune function (HHS, 2014). Mortality among current smokers is two to three times that of persons who never smoked (Jha et al. 2013). Since the first Surgeon General’s Report on Smoking and Health in 1964, cigarette smoking has killed more than 20 million people in the U.S. (HHS 2014). Between 2005-2009, 87% of lung cancer deaths, 61% of all pulmonary disease deaths, and 32% of all coronary heart disease deaths were attributable to smoking and secondhand smoke exposure (HHS, 2014), making it an essential risk factor to address to reduce both disease burden and health care costs. The toll smoking takes on health extends beyond the smokers. Since 1964, almost 2.5 million nonsmoking adults have died from heart disease and lung cancer caused by exposure to secondhand smoke, and 100,000 babies have died of sudden infant death syndrome or complications from prematurity, low birth weight, or other conditions caused by parental smoking, particularly smoking by the mother (HHS, 2014). Reducing cigarette smoking in the community can impact the health and health care costs of nonsmokers as well. CDC (Centers for Disease Control and Prevention). (2014a). CDC’s Tips from Former Smokers campaign provided outstanding return on investment. Atlanta, GA. Available at: http://www.cdc.gov/media/releases/2014/p1210-tips-roi.html. (Accessed 27 October, 2015). HHS (US Department of Health and Human Services). (2014). The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Available at: http://www.surgeongeneral.gov/library/reports/50-years-of-progress/full-report.pdf. (Accessed 23 September, 2015). Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. (2014) Annual Healthcare Spending Attributable to Cigarette Smoking: An Update. American Journal of Preventive Medicine, 48(3), p.326-333. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4603661/ (Accessed 24 September, 2015). Jha, P. and Peto, R. (2014). Global effects of smoking, of quitting, and of taxing tobacco. New England Journal of Medicine, 2014(370), p.60-68. Available at: http://www.nejm.org/doi/full/10.1056/nejmra1308383. (Accessed 22 October, 2015). doi: 10.1056/NEJMra1308383

Summary of NQF Endorsement Review





Appendix B: Program Summaries

The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program Index


Full Program Summaries

Medicare Shared Savings Program 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: Section 3022 of the Affordable Care Act (ACA) requires the Centers for Medicare & Medicaid Services (CMS) to establish a Shared Savings Program that promotes accountability for a patient population, coordinates items and services under Medicare Parts A and B, and encourages investment in infrastructure and redesigned care processes for high-quality and efficient service delivery. The Medicare Shared Savings Program (MSSP) was designed to facilitate coordination and cooperation among providers to improve the quality of care for Medicare Fee-For-Service (FFS) beneficiaries and reduce the rate of growth in health care costs. Eligible providers, hospitals, and suppliers may participate in the Shared Savings Program by creating or participating in an Accountable Care Organization (ACO). If ACOs meet program requirements and the ACO quality performance standard, they are eligible to share in savings, if earned. There are three shared savings options: 1) one- sided risk model (sharing of savings only for the first two years, and sharing of savings and losses in the third year), 2) two-sided risk model (sharing of savings and losses for all three years), and 3) two-sided risk model (sharing of savings and losses for all three years) with prospective assignment

High Priority Domains for Future Measure Consideration: N/A

Measure Requirements:

Specific measure requirements include:

  1. Outcome measures that address conditions that are high-cost and affect a high volumeof Medicare patients.
  2. Measures that are targeted to the needs and gaps in care of Medicare fee-for-service patients and their caregivers.
  3. Measures that align with CMS quality reporting initiatives, such as MIPS.
  4. Measures that support improved individual and population health.
  5. Measures that align with recommendations from the Core Quality Measures Collaborative.

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.

Merit-Based Incentive Payment System 
The material in this appendix was drawn from the CMS Program Specific Measure Priorities and Needs document, which was released in April 2016.

Program History and Structure: The Merit-Based Incentive Payment System (MIPS) is established by H.R. 2 Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), which repeals the Medicare sustainable growth rate (SGR) and improves Medicare payment for physician services. The MACRA consolidates the current programs of the Physician Quality Reporting System (PQRS), The Value-Based Modifier (VM), and the Electronic Health Records (EHR) Incentive Program into one program (MIPS) that streamlines and improves on the three distinct incentive programs. MIPS will apply to doctors of medicine or osteopathy, doctors of dental surgery or dental medicine, doctors of podiatric medicine, doctors of optometry, chiropractors, physician assistants, nurse practitioners, clinical nurse specialists, and certified registered nurse anesthetists beginning in 2019. Other professionals paid under the physician fee schedule may be included in the MIPS beginning in 2021, provided there are viable performance metrics available. Positive and negative adjustments will be applied to items and services furnished beginning January 1, 2019 based on providers meeting a performance threshold for four performance categories: quality, resource use, clinical practice improvement activities, and meaningful use of certified EHR technology. Adjustments will be capped at 4 percent in 2019; 5 percent in 2020; 7 percent in 2021; and 9 percent in 2022 and future years.

High Priority Domains for Future Measure Consideration:

CMS will not propose the implementation of measures that do not meet the MIPS criteria of performance and measure set gaps. MIPS has a priority focus on outcome measures and measures that are relevant for specialty providers. CMS identifies the following domains as high-priority for future measure consideration:

  1. Person and caregiver-centered Experience and Outcomes
    • CMS wants to specifically focus on patient reported outcome measures (PROMs)
  2. Communication and Care Coordination
    • Measures addressing coordination of care and treatment with other providers
  3. Appropriate Use and Resource Use
  4. Patient Safety

In addition, CMS identified the following measure types as high-priority for future measure consideration:

  1. Outcome measures
  2. Appropriate Use of Services measures
  3. Patient Experience measures
  4. Care Coordination measures

Measure Requirements:

CMS applies criteria for measures that may be considered for potential inclusion in the MIPS. At a minimum, the following criteria and requirements must be met for selection in the MIPS: CMS is statutorily required to select measures that reflect consensus among affected parties, and to the extent feasible, include measures set forth by one or more national consensus building entities. To the extent practicable, quality measures selected for inclusion on the final list will address at least one of the following quality domains: clinical care, safety, care coordination, patient and caregiver experience, and population health and prevention. In addition, before including a new measure in MIPS, CMS is required to submit for publication in an applicable specialty-appropriate, peer-reviewed journal the measure and the method for developing the measure, including clinical and other data supporting the measure.

  1. Measures implemented in MIPS may be available for public reporting on Physician Compare.
  2. Preference will be given to electronically specified measures (eCQMs)
  3. eCQMs must meet EHR system infrastructure requirements, as defined by the future MIPS regulation.
    • The data collection mechanisms must be able to transmit and receive requirements as identified in future MIPS regulation. For example, eCQMs must meet QRDA standards.
  4. Measures must be fully developed and tested.
    • Reliability and validity testing must be conducted for measures.
    • Feasibility testing must be conducted for eCQMs.
  5. Measures should not duplicate other measures currently in the MIPS. Duplicative measures are assessed to see which would be the better measure for the MIPS measure set.
  6. Measure performance and evidence should identify opportunities for improvement. CMS does not intend to implement measures in which evidence identifies high levels of performance with little variation or opportunity for improvement, e.g., measures that are “topped out."

Current Measures: NQF staff have compiled the program's measures in a spreadsheet organized according to concepts.


Appendix C: Public Comments

Index of Measures (by Program)

All measures are included in the index, even if there were not any public comments about that measure for that program.

General Comments

Merit-Based Incentive Payment System

Medicare Shared Savings Program


Full Comments (Listed by Measure)

General
  • (Early public comment)General comment-We were concerned that no measures were approved for either hospital acquired conditions or hospital readmissions per Appendix C. Although hospital readmissions are down this year, data indicates that 30% of pediatric readmissions are preventable (source: https://pediatrics.aappublications.org/content/early/2016/07/20/peds.2015-4182). Hospital acquired conditions data has improved as CMS notes “across the FY 2015 and FY 2016 programs, the average performance across eligible hospitals improved on two of the three measures included in both program years” (source: https://www.acep.org/Clinical---Practice-Management/Health-Care-Acquired---Provider-Preventable-Conditions-FAQ/.) Nevertheless, there is increasing awareness of “superbugs” and most hospital acquired infections by their very nature are preventable. Addressing this will decrease costs and improve health care outcomes. (Submitted by: Statewide Parent Advocacy Network/Family Voices NJ)

  • (Early public comment)· No quality measure should be publicly reported without having been collected and reported in the same fashion and subject to the same processes as a HEDIS first year measure. · Any publicly reported quality measure must at least meet the NQF criteria for measure endorsement. The NQF criteria require the measure be: o Important to measure and report, where the evidence is highest that measurement can have a positive impact on healthcare quality. o Scientifically acceptable, so that the measure when implemented will produce consistent (reliable) and credible (valid) results about the quality of care. o Useable and relevant to ensure that intended users — consumers, purchasers, providers, and policy makers — can understand the results of the measure and are likely to find them useful for quality improvement and decision making. o Feasible to collect with data that can be readily available for measurement and retrievable without undue burden." · Performance reports aimed at consumers must be displayed in a way that is easily understood by a consumer. Performance reports developed for clinicians would require a different, more detailed format. (Submitted by: Kaiser Permanente)

  • (Early public comment)Asking whether or not a patient received pain medication during their visit automatically ensures negative responses in many cases. These questions should focus on pain assessment and treatment in general, not on the prescribing of medication. (Submitted by: Community Health Network)

  • (Early public comment)Centers for Medicare & Medicaid Services Department of Health and Human Services Mail Stop C4-26-05 Baltimore, MD 21244-8050 Re: MAP Pre-Rulemaking 2016-2017: Comment on Measures Under Consideration CVS Health is pleased to provide comments in response to the Centers for Medicare & Medicaid Services (CMS) request for comments on the list of Measures Under Consideration (MUC) for NQF’s Measure Applications Partnership (MAP), which provides input to HHS and private sector initiatives on measures for use in public reporting, performance-based payment, and other programs. CVS Health is a pharmacy innovation company helping people on their path to better health. Through its more than 7,900 retail drugstores, more than 1,000 walk-in medical clinics, a leading pharmacy benefits manager with more than 70 million plan members, a dedicated senior pharmacy care business serving more than one million patients per year, and expanding specialty pharmacy services, the Company enables people, businesses and communities to manage health in more affordable, effective ways. This unique integrated model increases access to quality care, delivers better health outcomes and lowers overall health care costs. The Pharmacy Services Segment provides a full range of pharmacy benefit management (PBM) services to our clients consisting primarily of employers, insurance companies, unions, government employee groups, managed care organizations (MCOs) and other sponsors of health benefit plans and individuals throughout the United States. Background The Centers for Medicare & Medicaid Services (CMS) issued the List of Measures under Consideration (MUC) to comply with Section 1890A(a)(2) of the Social Security Act (the Act), which requires the Department of Health and Human Services (DHHS) to make publicly available a list of certain categories of quality and efficiency measures it is considering for adoption through rulemaking for the Medicare program. Among the measures, the list includes measures CMS is considering that were suggested to by the public. When organizations, such as physician specialty societies, request that CMS consider measures, CMS attempts to include those measures and make them available to the public so that the Measure Applications Partnership (MAP), the multistakeholder groups convened as required under 1890A of the Act, can provide their input on all potential measures and ensure alignment where appropriate. The list is larger than what will ultimately be adopted by CMS for optional or mandatory reporting programs in Medicare. CMS will continue its goal of aligning measures across programs. Measure alignment includes establishing core measure sets for use across similar programs, and looking first to existing program measures for use in new programs. Further, CMS programs must balance competing goals of establishing parsimonious sets of measures, while including sufficient measures to facilitate multispecialty provider participation. CVS Health Comments CVS Health appreciates the opportunity to provide comments, especially as it pertains to measures for inclusion in the the Merit-based Incentive Payment System (MIPS). PBMs, pharmacies, and pharmacists play an integral role in health quality outcomes. With the Medicare Access & CHIP Reauthorization Act (MACRA) moving health plans and health care providers into alternative payment models, pharmacists are in an important position within the value-based care transition to assist in quality metrics that have an emphasis on medication management and optimization of medication use. Providing comprehensive pharmacy care management services, such as immunization, diabetes, hypertension, high cholesterol management and medication reconciliation post inpatient discharge helps to drive population health and chronic disease management. Pharmacists have an important role in partnering with the health care team. Through the MIPS program CMS proposes that most MIPS-eligible clinicians would be required to report on at least six quality measures, including at least one cross-cutting measure and an outcome measure if available. Evidence supports that optimal prescription utilization has a positive impact on reducing the total cost of care, increasing patient safety and improving clinical outcomes. A successful MIPS strategy will be dependent on a clear definition of goals and measures to monitor the effectiveness of the value based approach. Prescription drugs have been shown to lower overall medical costs through reduced hospitalization, emergency room utilization and outpatient visits, while medication therapy management programs and pharmacy counseling play an important role in optimizing prescription adherence to improve quality outcomes for individuals with chronic conditions. Through the implementation of the Medicare Part D program, prescription coverage has been shown to reduce Medicare Parts A and B medical expenses for beneficiaries compared to those with no or limited prior drug coverage. Research conducted by CVS Health also indicates that investment in resources to improve drug adherence among Medicare Part D beneficiaries has been shown to lower overall medical costs through reduced hospitalization, emergency room utilization and outpatient visits. CVS Health encourages balance and parsimony in the selection of quality measures to monitor the quality performance. In pursuit of consistency, parsimony, and reducing the burden of measurement and reporting, the alignment of measures across federal programs should be an important health system priority. Alignment, or use of the same or related high value measures when appropriate, is a critical strategy for accelerating improvement in priority areas, reducing duplicative data collection and enhancing comparability and transparency of quality performance. CVS Health was encouraged by the alignment of MIPS measures with measures used in other government programs (e.g., Medicare STARS, Medicaid Core Sets, Health Insurance Marketplaces, etc.) when possible. Therefore we were pleased to see several pharmacy influenced measures proposed for MIPS, such as: • Antidepressant medication management • Medication management for people with Asthma • Medication reconciliation post-discharge and Management in Women who had a Fracture • Controlling high blood pressure, etc. CVS Health would like recommend the following measures that align with measures used in other Federal programs for inclusion: Measure Recommendations Rationale Proportion of Days Covered – 3 rates While measures such as “Documentation of Current Medications in the Medical Record” and “Medication Reconciliation Post-Discharge” are key indicators of high quality medication management, additional measures that assess medication adherence are necessary to ensure that patients are actually receiving the therapy they need. A strong case can be made for the importance of physician insight into their patients’ medication adherence enabling them to make informed decisions regarding therapeutic choices, and which could improve patient empowerment to take their medications. We would recommend the “Proportion of Days Covered (PDC) – three rates” measure be included in the MIPs due to its proven ability to help improve medication adherence and health outcomes in the Medicare Stars program. Proportion of Days Covered (PDC) is the Pharmacy Quality Alliance (PQA)-recommended metric for estimation of medication adherence for patients using chronic medications. This metric is also endorsed by the National Quality Forum (NQF). The metric identifies the percentage of patients taking medications in a particular drug class that have high adherence (PDC > 80% for the individual). The measure tracks medication adherence for conditions that are highly prevalent in Medicare-Medicaid populations. It includes three rates - one for blood pressure medications (renin angiotensin system antagonists [RASA]), one for cholesterol medications (statins), and one for diabetes medications (roll-up across 4 classes of oral diabetes drugs). A form of this measure is currently being used in Medicare STARS and the Health Insurance marketplaces. Inclusion in MIPS would allow further alignment across programs to promote consistent performance measurement where it can have the most impact and give a more complete view of the quality of care delivered across healthcare settings. Proportion of days covered: Antiretroviral adherence for HIV-specialists. Again, while the Prescription of HIV Antiretroviral Therapy measure is a key indicator of high quality medication management, evaluation of medication adherence is necessary to ensure that patients are actually receiving the therapy they need. Human immunodeficiency virus (HIV) can cause life-long infection that results in a chronic debilitating disease usually ending in death. Adherence to multiple anti-HIV medications has been shown to dramatically slow the progression of disease and prolong survival. This measure is used to assess the percentage of patients 18 years and older who filled a prescription for at least two individual antiretroviral drugs (as single agents or as a combination) on two unique dates of service who met the Proportion of Days Covered (PDC) threshold of 90% during the measurement period. Antiretroviral adherence is currently a Part D Patient Safety measure, reported monthly though the Acumen Patient Safety Analysis website. Rheumatoid Arthritis (RA): Disease Modifying Anti-Rheumatic Drug (DMARD) Therapy This measure is used to monitor the percentage of patients aged 18 years and older who were diagnosed with rheumatoid arthritis (RA) and were prescribed, dispensed, or administered at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD). This measure calculates the percent of plan members with Rheumatoid Arthritis who got one or more prescription(s) for a DMARD, pivotal to long term treatment. Further, inclusion of the RA measure would align with the measure used in the Medicare STARS program. Antipsychotic Use in Persons with Dementia (APD) CMS has been particularly concerned with the unnecessary use of antipsychotic drugs particularly in nursing homes and, as a result, has pursued strategies to increase awareness of antipsychotic use in long term care settings. In 2013, CMS began to calculate a general atypical antipsychotic utilization rate, called Rate of Chronic Use of Atypical Antipsychotics by Elderly Beneficiaries in Nursing Homes, for inclusion in the Part D display measures. The average rates decreased from approximately 24.0% in 2011 to 21.4% in 2013. There continues to be increased attention on this important issue. The United States Government Accountability Office (GAO) released a report in January 2015 describing the inappropriate use of antipsychotics in Part D beneficiaries with dementia, in both community (i.e., outside of nursing homes) and long-stay nursing home residents during 2012, with Antipsychotic Drug Use. The GAO conducted this study due to concerns raised regarding the use of antipsychotic drugs to address the behavioral symptoms associated with dementia, the FDA’s boxed warning that these drugs may cause an increased risk of death when used by older adults with dementia, and because the drugs are not approved for this use. HHS has Initiatives to reduce use among older adults in nursing homes, but should consider expanding efforts to other settings. Further, inclusion would align with the Medicare display measure and Part D Patient Safety measure. Statin Use in Persons with Diabetes The American College of Cardiology/American Heart Association (ACC/AHA) guidelines recommend moderate- to high-intensity statin therapy for primary prevention for persons aged 40 to 75 years with diabetes. This measure is used to assess the percentage of patients ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication. This measure is very much prescriber influenced and inclusion will align with the health care system goals. Further, inclusion of “Statin Use in Persons with Diabetes” would align with the Medicare display measure and Part D Patient Safety measure. Use of Opioids from Multiple Providers or at High Dosage in Persons Without Cancer CVS Health recommends the inclusion of all three measures. • Measure 1: Use of Opioids at High Dosage • Measure 2: Use of Opioids from Multiple Providers • Measure 3: Use of Opioids at High Dosage and from Multiple Providers Measure one can be directly influenced by providers while measure 3 would also align with the Medicaid adult core set measure adopted in 2016. These measures are currently Part D Patient Safety measures, reported monthly though the Acumen Patient Safety Analysis website. CVS Health appreciates the opportunity to provide comments to CMS. If you have any questions, please feel free to contact Emily Kloeblen at Emily.Kloeblen@cvshealth.com. Sincerely, Emily Kloeblen Director, Government Performance Measures CVS Health (Submitted by: CVS Health)

  • (Early public comment)I am not commenting by individual MUC but some general thoughts/concerns. I would still like to see us focus on strategy that drives us selecting the critical few measures that will build a healthy American and place them in the appropriate program where the responsibility lies verses in some of the inpatient measures where the patient is for such a short time and there really is no way the intervention will be sustained.I was concerned about the tobacco measures since I thought those were topped out and did not know why they were back in. Are the opiods in the correct program to be fully managed and see ongoing improvement of the user of the opiod? The EHR use for med rec in the behavioral health measure may not be feasible due to the lack of sophistication of the EHR in the behavioral world but the concept of the med rec is good. I also think that the cancer measures are a lot and have artificial boundaries for outpatient and inpatient. in this disease like many of the chronic illnesses it is about the patients treatment plan not the location of the care. I (Submitted by: American Hospital Association representative on the MAP Coordinating Committee)

  • (Early public comment)General Comments: The Federation of American Hospitals (FAH) appreciates the opportunity to provide comments on the Measures Under Consideration (MUC) list prior to the individual workgroup discussions and voting. The FAH believes that the Measures Application Partnership (MAP) should support only those measures that truly represent the quality of care provided within a hospital, physician or other provider. Any new measures added to these programs should focus on a targeted set of issues and topics, effectively leverage electronic health record systems and other health information technologies, and drive improvement in the overall delivery of patient care. In addition, we ask that the MAP be judicious in selecting measures where there is limited evidence that improvements (or lack thereof) on the process or outcome of interest are within the control of the measure entity (e.g., follow-up after hospitalization for mental illness) or where performance has proven to be generally high (e.g., the tobacco use measures). (Submitted by: Federation of American Hospitals )

Adult Local Current Smoking Prevalence (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-069)
  • (Early public comment)Prevention Institute supports the Measure Applications Partnership proposed measure on Adult Local Current Smoking Prevalence (MUC16-69). As a leading cause of preventable death and disease, it is imperative that healthcare actively work to reduce smoking prevalence not only among a designated patient population but also within the greater community where patients reside. Establishing quality metrics like MUC16-69 that encourage healthcare to engage in community-wide prevention strategies is an important first step to improving population health, a cornerstone of the Triple Aim. MUC16-69 further serves as a model for encouraging hospitals and health systems to develop strategic and purposeful partnerships beyond the walls of the healthcare institution where the vast majority of health is created. Since smoking prevalence data is already collected annually by the Behavioral Risk Factor Surveillance Survey, the inclusion of MUC16-69 would not add additional burden of data collection or reporting. Finally, we encourage measures like MUC16-69 to be employed not just for the Merit-based Incentive Payment System but for all Centers for Medicare and Medicaid value-based payment programs in order to promote further alignment with the National Prevention Strategy and Healthy People 2020. (Submitted by: Prevention Institute)

  • (Early public comment)MUC16-069 looks at % of adult population in a county and their smoking prevalence rate. Looking for improvement on this measure to assess health care providers in their ability to reduce smoking is problematic for a few reasons: 1) baseline performance is likely very variable across the country, depending on local social behavior patterns, demographics, income, patient peer groups, BH comorbidity, etc; 2) the degree to which health care providers can reduce patient smoking is also variable for similar factors. Providers can perform well on this measure by caring for a less sick population – and conversely perform poorly when caring for sicker populations. Performance will thus likely be based more on population factors than clinical intervention. (Submitted by: AMGA)

  • (Early public comment)MUC16-69: Adult Local Current Smoking Prevalence: While the American Medical Association (AMA) does not disagree with the importance of tracking smoking prevalence, we do not believe that it is appropriate for this measure to be used in the MIPS and MSSP programs. Reporting the prevalence of tobacco use within a county at the physician or Accountable Care Organization (ACO) level does not provide meaningful and actionable information to physicians, other providers or patients within a community. Specifically, we do not believe that this measure is directly applicable and appropriately tested at either level. Perhaps more importantly, the measure developer has not adequately demonstrated how individual physicians or an ACO can influence a county smoking prevalence rate. The measure must address the community factors that can impact a patient’s ability to successfully quit smoking, including the availability of tobacco use cessation programs (CDC, 2014). Any new measures added to these programs should focus on areas that can help to drive improvement in the overall delivery of patient care, while also truly representing the quality of care provided by the measured entity. Reference: Centers for Disease Control and Prevention. Best practices for comprehensive tobacco control programs - 2014. Available at: http://www.cdc.gov/tobacco/stateandcommunity/best_practices/pdfs/2014/comprehensive.pdf. Accessed December 1, 2016. (Submitted by: American Medical Association)

  • (Early public comment)CMS is commended for pursuing measures for our health care system that are "upstream," such as MUC16-69, an outcome measure of Adult Local Current Smoking Prevalence, based on the CDC’s Behavioral Risk Factor Surveillance System. The Vital Signs: Core Metrics for Health and Health Care Progress report recognizes tobacco use as a core metric for a parsimonious measurement set for health and health care. The Performance Measures White Paper of the Population-based Payment Workgroup of the Health Care Payment Learning and Action Network (LAN) recognizes healthy behaviors, e.g., tobacco use, as a candidate for a "big dot" population outcome measure for better health in the Triple Aim. The proposed use of MUC16-69 in the Merit-based Incentive Payment System and Medicare Shared Services Program is consistent with these directions and should be supported. Thank you for the opportunity to comment. (Submitted by: HealthPartners Institute)

  • (Early public comment)The AAMC has concerns with inclusion of this measure in the MIPS and MSSP programs. In the CMS list of Measures Under Consideration, CMS did not provide an explanation as to how providers would be assessed under this measure. While we support reduction in smoking prevalence, we question whether it is appropriate to hold providers accountable for activity that is largely outside of their control. In addition, it is unclear as to how this measure would be applied and adjusted to account for factors, such as age, race/ethnicity, education, socioeconomic status, and geographic region. Before any new measure is submitted for inclusion, CMS and the MAP should ensure that the measure’s value added is greater than the burden required to collect and submit such data. (Submitted by: Association of American Medical Colleges)

  • (Early public comment)As Chair of the United States Public Health Services Panel that produced the Clinical Practice Guideline, Treating Tobacco Use and Dependence (2008) and as a practicing phyisician, I know well the extraordinary toll from tobacco use and the potential to help smokers quit using evidence-based treatments. To achieve these outcomes requires the systematic identification, documentation, and treatment of all tobacco users, both while hospitalized and upon discharge. By including this MUC16-068 measure, we will be able to better document and evaluate tobacco cessation interventions and support the TOB measures (1, 2, and 3). Tobacco use is the leading preventable cause of illness and death in the United States responsible for 480,000 deaths per year. We can prevent virtually all of these deaths - 20% of all deaths each year in America - if we systematically identify and treat patients who smoke. (Submitted by: University of Wisconsin Department of Medicine)

Adult Local Current Smoking Prevalence (Program: Medicare Shared Savings Program; MUC ID: MUC16-069)
  • (Early public comment)The AAMC has concerns with inclusion of this measure in the MIPS and MSSP programs. In the CMS list of Measures Under Consideration, CMS did not provide an explanation as to how providers would be assessed under this measure. While we support reduction in smoking prevalence, we question whether it is appropriate to hold providers accountable for activity that is largely outside of their control. In addition, it is unclear as to how this measure would be applied and adjusted to account for factors, such as age, race/ethnicity, education, socioeconomic status, and geographic region. Before any new measure is submitted for inclusion, CMS and the MAP should ensure that the measure’s value added is greater than the burden required to collect and submit such data. (Submitted by: Association of American Medical Colleges)

Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-074)
  • (Early public comment)As a nurse practitioner with the Heart Failure Clinic of St. Dominic Hospital in Jackson, Mississippi, I understand first-hand the need to drive the best available care for heart failure patients, and I see the most urgent need for improved care among my African American patients. I have used "Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate over the years and I have seen the 30 day readmission rate for my patients at less than 2 % per year. Accordingly, I strongly support proposed measure #16-074, the “Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure.” (Submitted by: Heart Failure Clinic at St. Dominic Hospita )

  • (Early public comment)The Association of Black Cardiologists appreciates the opportunity to submit this public comment to the Measures Applications Partnership in support of MUC 16-74, “Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-Identified Black or African American Patients with Heart Failure and Left Ventricular Ejection Fraction (LVEF) <40% on ACEI or ARB and Beta-blocker Therapy," which is under consideration for use by CMS in the Merit-based Incentive Payment System.   MUC 16-74 represents effective, evidence-based therapy that is based on the African- American Heart Failure Trial, which was completed over a decade ago; approval in 2005 by the FDA of the fixed-dose combination with the specific label indication for self-identified Blacks/African Americans; and almost 10 years of utilization and outcome data that documentlow-levels of use of this highly-effective therapy, and resulting unacceptable rates of preventable morbidity and mortality.   The Association of Black Cardiologists believes that MUC 16-74 represents a value- proposition for African-Americans with chronic heart failure, and for the physicians who treatthem. MUC 16-74 supports efforts to prevent unnecessary hospitalizations, to eliminate inequities in healthcare and health status, and to advance efforts to enhance precision in the design of treatment options that will improve the quality of healthcare.   The Association of Black Cardiologists encourages the Measure Applications Partnership to recommend approval of MUC 16-74, given the FDA has not approved a generic substitution for this combination. (Submitted by: Association of Black Cardiologists)

  • (Early public comment)To Whom It May Concern, On behalf of the Hepatitis Foundation International (HFI), we would like to contribute input on supporting CMS’ adoption of the measure submitted by the National Minority Quality Forum (#16-074) entitled: “Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-identified Black or African American Patients with Heart Failure”. HFI is a 501 (c) 3 non-profit organization established in 1994 working to eradicate chronic hepatitis for 550 million people globally. HFI is dedicated to increasing and promoting health and wellness, as well as, reducing the incidence of preventable liver-related chronic diseases and lifestyles that negatively impact the liver. Some of these diseases and issues addressed include; obesity, diabetes, hepatitis, harm reduction, substance abuse, HIV/AIDS, cardiovascular disease and fatty/liver cancer. The Hepatitis Foundation International implements its mission through our touchstones to educate, prevent, serve, support and reach over 5 million patients and health care professionals annually through our public and private partnerships. As a patient advocacy organization, we understand the barriers various racial and ethnic groups encounter when trying to receive quality health care and treatment. We believe that constant improvements, additional measures on education and training for various healthcare stakeholders, and community outreach will benefit these groups and help them receive quality health care and treatment. Research suggests a strong correlation between liver complications and congestive heart failure. A study from the Gastroenterology and Hepatology Peer-Reviewed Journal states that liver complications such as cirrhosis can make the liver more susceptible to ischemia which reduces cardiac output and causes congestive heart failure (Giallourakis 2013). Often these disease conditions have multiple comorbidity factors such as viral hepatitis, obesity and diabetes, which can impact heart failure. Raising awareness about the effects of these comorbidities will allow for measures of prevention and treatment to occur. HFI supports public and private partnership to prompt these actions and increase awareness for healthy behaviors and lifestyle to reduce comorbidities, especially among minorities and the underserved. Reducing these comorbidities can be a stepping stone in the right direction to prevent and maintain chronic conditions, such as congestive heart failure. In addition, continuous work with various advocacy groups as well as government healthcare agencies is urgent to raise awareness for therapeutic and cost effective treatments for conditions such as heart failure as it pertains to liver disease. The measure entitled “Fixed-dose Combination of Hydralazine and Isosorbide Dinitrate Therapy for Self-Identified Black or African American Patients with Heart Failure” was developed to decrease the incidence of heart failure among the African American population. There are over 1 million hospitalizations in the United States annually for heart failure, which contributes to health-related costs that exceed $40k annually, according to an article published in the American Journal of Cardiology (Ferdinand et al., 2014). Studies have shown that the therapy is beneficial in terms of mortality, morbidity, and quality of life, therefore the use of combination therapy will decrease economic strain in the United States. This form of therapy is marked at $1.80 a pill, roughly 4 to 7 times less costly than the individualized cost of hydralazine and isosorbide dinitrate (Brody et al., 2006). A less costly resort to therapy will ensure that the U.S. will see an overall decrease in healthcare costs. In addition, the combination use of Hydralazine and Isosorbide Dinitrate is recommended for African Americans and non-African Americans by the American College of Cardiology/American Heart Association and the Heart Failure Society of America under the Heart Failure management guidelines. Thank you for providing us the opportunity to comment on this issue. The Hepatitis Foundation International looks forward to assisting further as this process continues. Please do not hesitate to contact me directly at IFCameron@HepatitisFoundation.org or by telephone at (301)-565-9410 if we can be of further assistance. Sincerely, Ivonne Fuller Cameron President & CEO (Submitted by: Hepatitis Foundation International )

HIV Viral Suppression (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-075)
  • (Early public comment) Employees of the Janssen pharmaceutical family of companies participate in committees, work groups, boards and/or other functions at NQF and some of the sponsoring organizations for these measures (Submitted by: Johnson & Johsnon )

Average change in back pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-087)
  • (Early public comment)The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals. Specifically, NASS would like to provide comment on the following measures: - MUC16- 87 – Average change in back pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure. - MUC16- 88 – Average change in back pain following lumbar fusion: The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion surgery. - MUC16- 89 – Average change in leg pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure These three measures are being considered for inclusion in CMS’ Merit-based Incentive Payment System (MIPS). General Comments: - While assessing change in pain is a reasonable and standard approach, NASS asks how the data in these outcomes measures will be interpreted under MIPS. Specifically, the change in pain is correlated to the baseline value – the worse the baseline pain, the larger the potential for change. For example, a patient who has a baseline pain level of 8 can improve 8 points while a patient who has a baseline pain level of 4 can only improve for the maximum of 4 points. According to how pain is assessed in these measures, the practices with more severe patients could fare better as there is a greater potential for change in pain. If these measures are included in MIPS, NASS requests clarification as to how the data in these measures will be used to measure clinician performance. - While NASS appreciates the efforts to define spine issues, these measures are oversimplified. We request that the measures be modified so they can more accurately differentiate surgeon goals, approaches, and patient metrics. - NASS does not support inclusion of measure MUC16-87 – Average change in back pain following lumbar discectomy and/or laminotomy – in MIPS. NASS does not believe measuring back pain following lumbar discectomy is appropriate. Leg pain is a more appropriate metric for change following a discectomy rather than low back pain. Discectomy is mainly associated with leg pain. Conditions such as degenerative scoliosis, spondylolsis, etc. treated with fusion are often associated with both leg pain and low back pain. Specific Comments on Measures: MUC16- 87 – Average change in back pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in back pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure. - General Comments: o NASS does not believe measuring back pain following lumbar discectomy is appropriate. Leg pain is a more appropriate metric for change following a discectomy rather than low back pain. Discectomy is mainly associated with leg pain. Conditions such as degenerative scoliosis, spondylolsis, etc. treated with fusion are often associated with both leg pain and low back pain. Therefore, NASS does not support inclusion of this measure for inclusion in MIPS. - Measure Denominator: The measure denominator includes patients age 18 years and older at the start of the procedure measurement period o In general, the patient population this measure captures seems appropriate. o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focuses primarily on the Medicare population. - Measure Denominator Exclusions: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population. Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. - Timing of Measurement: o The measurement timeframe provides a window of 6 to 20 weeks to measure low back pain. Literature demonstrates that pain improvement is not complete at 6 weeks. Specifically, pain scores collected at 6 weeks are somewhat higher compared to pain scores collected at 12 weeks. Furthermore, many patients typically use opiates immediately following operation, rendering early pain measurement less reliable. Therefore, NASS recommends that the measurement timeframe be more narrow, particularly immediately following operation. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale. The VAS and NRS are two different approaches in measuring pain. Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done. Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS. Alternatively, the NRS could be used as the unit of measurement. (Submitted by: North American Spine Society)

Average change in back pain following lumbar fusion. (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-088)
  • (Early public comment)The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals. MUC16- 88 – Average change in back pain following lumbar fusion: The average change (preoperative to one year postoperative) in back pain for patients 18 years of age or older who had lumbar spine fusion surgery. - Measure Denominator: The measure denominator includes patients age 18 years and older at the start of the procedure measurement period o In general, the patient population this measure captures seems appropriate. o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focuses primarily on the Medicare population. o The inclusion criteria do not adequately stratify patients. For example, a surgeon who predominantly performs fusions for deformity corrections has a very different patient population than one who performs degenerative fusions. NASS recommends that the measure be stratified by the number of fusion levels performed. Generally, a 1-2 level fusion is used for degenerative cases, whereas deformity cases generally have greater than 3 levels of fusion or more. - Measure Denominator Exclusion: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population. Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale. The VAS and NRS are two different approaches in measuring pain. Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done. Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS. Alternatively, the NRS could be used as the unit of measurement. (Submitted by: North American Spine Society)

Average change in leg pain following lumbar discectomy and/or laminotomy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-089)
  • (Early public comment)The North American Spine Society (NASS) appreciates the opportunity to comment on the National Quality Forum (NQF) Measure Applications Partnership’s (MAP) 2016 Measures Under Consideration List. NASS is a multispecialty medical organization dedicated to fostering the highest quality, evidence-based, ethical spine care by promoting education, research and advocacy. NASS is comprised of more than 8,000 physician and non-physician members from several disciplines, including orthopedic surgery, neurosurgery, physiatry, pain management, neurology, radiology, anesthesiology, research, physical therapy and other spine care professionals. MUC16- 89 – Average change in leg pain following lumbar discectomy and/or laminotomy: The average change (preoperative to three months postoperative) in leg pain for patients 18 years of age or older who had lumbar discectomy laminotomy procedure - Measure Denominator: The measure denominator includes patients age 18 years and older at the start of the procedure measurement period. o In general, the patient population this measure captures seems appropriate. o As these measures are newly developed, the measure’s denominator should capture a more targeted population that focuses primarily on the Medicare population. - Measure Denominator Exclusions: o NASS requests that MNCM exclude patients who are primarily diagnosed with neurogenic claudication, particularly in the Medicare population. Patients with this diagnosis may not report much preoperative leg pain or back pain in the clinical setting as their symptoms are primarily elicited on exertion only. - Timing of Measurement: o NASS notes that many patients typically use opiates immediately following operation, rendering early pain measurement less reliable. Therefore, NASS recommends that the measurement timeframe be more narrow, particularly immediately following operation. - Unit of Measurement: Visual analog scale (VAS) to measure back pain and leg pain. o While these measures require use of the VAS scale, the submission of data requests that the answers are provided as if they were obtained on the NPR scale. The VAS and NRS are two different approaches in measuring pain. Converting metrics collected from one system to another system is confusing and potentially prone to inaccuracies if the conversions are not properly done. Therefore, NASS recommends that if the VAS scale is used, the system should accept the original VAS data, not the data converted from VAS to NRS. Alternatively, the NRS could be used as the unit of measurement. (Submitted by: North American Spine Society)

Febrile Neutropenia Risk Assessment Prior to Chemotherapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-151)
  • (Early public comment)Many patients are not properly assessed prior to chemotherapy. This will add value and improve outcomes. The data collection could be significant, so a method to streamline this will need to be carefully evaluated. (Submitted by: The Society for Healthcare Epidemiology of America)

Otitis Media with Effusion: Systemic Corticosteroids - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-268)
  • (Early public comment)Avoiding ineffective therapies will add value and improve outcomes (by reducing adverse events associated with inappropriate therapies). (Submitted by: The Society for Healthcare Epidemiology of America)

Otitis Media with Effusion: Systemic Antimicrobials - Avoidance of Inappropriate Use (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-269)
  • (Early public comment)While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: American Academy of Otolaryngology - Head and Neck Surgery)

Postoperative Plan Communication with Patient and Family (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-277)
  • (Early public comment)Overview The American College of Surgeons (ACS) is eager to promote the concept of measuring a patients “phases of care,” beginning with the Surgical Phases of Care Measures (SPCM) which is a patient-centered, comprehensive, and cross cutting approach to surgical measurement. The SPCM includes all measures which have been noted as by CMS on the MUC list as the “Group measure as defined by Am. Coll. of Surgeons.” However, based on the MAP Coordinating Committee’s criteria for inclusion of measures in national programs, we agree that MUC measures presented to the NQF MAP should be further tested for demonstration of the various aspects of feasibility, reliability, usability and validity. We have concerns that our initial surgical SPCM measure set does not have the level of rigorous analysis the ACS typically provides to the NQF or MAP. Therefore, we respectfully would prefer to initially include these measures in the ACS Qualified Clinical Data Registry (QCDR) , and potentially in an Advanced APM program prior to national implementation in the MIPS program. This would provide the ACS and the NQF MAP the level of confidence needed before promoting full scale deployment in the MIPS program. Therefore, we seek the NQF MAP’s support in the “direction” of this surgical measure framework. Background and Rationale Every surgical patient in each specialty walks through the phases of surgical care, and each of these phases involves key processes, critical care coordination with primary care physicians and anesthesia, as well as the technical side of surgical care that relates to safety, outcomes and preventing avoidable harms. As we move toward value-based surgical care system, a framework that values these phases is required. These metrics are different from measures in the current MIPS program because they broadly apply to almost all surgeons, span across the various phases of surgical care (preoperative, perioperative, intraoperative, postoperative, post discharge), and when measured together they can have a real impact at the point of care. The SPCM measure framework was constructed to allow for more detailed, procedure-specific metrics and patient reported outcome measures to be added when necessary. We believe this measure framework also aligns well with CMS’ efforts in episode based care and other alternative care programs. SPCM Measures as a Group On the MUC list, CMS notes that the SPCM measure was submitted by ACS as a measures group. It is important to clarify that it is not the intention of the ACS that surgeons would report across a “group” of seventeen measures. The reporting burden for reporting seventeen measures coupled with denominators that span across nearly all surgical patients would be extremely onerous. Rather, we would encourage surgeons to choose the required number of measures in MIPS (six measures, including one outcome measures) from the SPCM set and that those six measures span across the phases of surgical care. In an alternative payment model, select SPCMs can be rolled into a composite. We encourage future conversations on group reporting across a broader set of measures once interoperability and data exchange is enabled to the extent that would allow for easy flow of data to be captured across all surgical patients and thereby drastically reduce the reporting burden. However, we are many years away from the level of interoperability that would enable that level of data flow. (Submitted by: The American College of Surgeons)

Patient Frailty Evaluation (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-278)
  • (Early public comment)CAPC recommends the use of this measure for MIPS. (Submitted by: Center to Advance Palliative Care)

Postoperative Review of Patient Goals of Care (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-284)
  • (Early public comment)The National Coalition for Hospice and Palliative Care, representing the eight leading national professional organizations in hospice and palliative care, strongly recommends the inclusion of this measure in the MIPS. (Submitted by: National Coalition for Hospice and Palliative Care)

  • (Early public comment)CAPC recommends the use of this measure for MIPS. (Submitted by: Center to Advance Palliative Care)

Participation in a National Risk-adjusted Outcomes Surgical Registry (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-286)
  • (Early public comment)We support the general concept of involvement in clinical registry programs, but we are concerned about the specification of “national” here. There are good examples of state or regional registries that not only have all of the features and benefits of national registries, but they also have active collaborative quality improvement features that the national registries do not have. The Northern New England Cardiovascular Disease Study Group and the set of collaborative QI programs sponsored by Blue Cross Blue Shield of Michigan stand as excellent examples of these state or regional registries. If the measure is adopted, the word “national” should be replaced by something allowing for participation in non-national programs that actually have stronger QI features. (Submitted by: Henry Ford Health System)

Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-287)
  • (Early public comment)While written comments were not provided, the commenter indicated their support for this measure in this program (Submitted by: Johnson&Johnson )

  • (Early public comment)The American Society for Radiation Oncology (ASTRO) supports the clinical concept behind MUC16-287 “Bone Density Evaluation for Patients with Prostate Cancer and Receiving Androgen Deprivation Therapy (ADT)” and thereby supports its inclusion in the Merit-Based Incentive Payment System (MIPS) program. While we generally agree with the measure, we believe the current denominator, “diagnosis of prostate cancer, [and] current or past usage of androgen deprivation therapy,” is too broad. We anticipate there will be many abstraction issues with identifying all past administrations of ADT for a particular patient. We believe the bone density assessment should be limited to prostate cancer patients prescribed long-term, defined as more than 12 months of ADT (gonadotropin-releasing hormone [GnRH] agonist or antagonist]). Conversely, we find the numerator time frame, “Patient with DEXA scan or bone mineral density scan initially or within 3 months of ADT initiation,” to be narrowly defined. A baseline bone density scan can be assessed up to 3 months prior to the ADT initiation and would be a clearer description of “initially” in the numerator. Overall, ASTRO believes this measure would improve quality care for patients and supports the inclusion of this measure in MIPS with the proposed revisions and clarification. (Submitted by: American Society for Radiation Oncology)

Surgical Plan and Goals of Care (Preoperative Phase) (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-288)
  • (Early public comment)CAPC recommends the use of this measure for MIPS. (Submitted by: Center to Advance Palliative Care)

Preventative Care and Screening: Tobacco Screening and Cessation Intervention (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-289)
  • (Early public comment)We fully support and strongly recommend inclusion of this measure. Tobacco use is the number one cause of preventable deaths in the United States. (Submitted by: University of Wisconsin Center for Tobacco Research and Intervention)

  • (Early public comment)Tobacco use effects almost every part of the human body. It causes lung disease, a myriad of cancers including lung cancer, as well diabetes and heart disease just to name a few. Screening for and treating tobacco use prior to surgery can improve outcomes and increase the number of tobacco user who quit. By including this measure in the Merit-Based Incentive Payment System (MIPS), healthcare providers will be encouraged to screen and counsel their patients on tobacco cessation. This intervention’s benefits are two-fold. Encouraging tobacco users to quit before non-emergency surgery will improve outcomes of the surgery and speed up recovery. In addition by stopping tobacco use, these patients are improving their health in general and reducing their risk of tobacco caused disease. The American Lung Association strongly supports the inclusion of this measure in the MIPS program because of the positive impact it will have on patients. (Submitted by: American Lung Associaiton )

Patient Experience with Surgical Care Based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS) ® Surgical Care Survey (S-CAHPS) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-291)
  • (Early public comment)The American Academy of Ophthalmology supports this measure which evaluates physicians on results from Surgical CAHPS® survey. The S-CAHPS Survey was developed by the American College of Surgeons and a broad array of other surgical groups including the Academy to assess patient experience with surgical care. Prior to the development of the S-CAHPS survey, specialty surgical and anesthesia societies reviewed the CAHPS® Clinician and Group Survey and identified gaps in its content and approach related to the assessment of surgical care. Some of the critical gaps identified in the survey include informed consent, shared decision making, anesthesia care, and post-operative instructions and access—all of which are issues consumers find to be very important in surgery. The S-CAHPS Survey was developed to fill these gaps and collect patient experience information after surgical care. Ophthalmologists now distribute the S-CAHPS to their patients to meet the requirements of PQRS measure 304: Patent Satisfaction within 90 Days Following Cataract Surgery, a component of the Cataracts Measures Group. We recommend that MAP favorably review this measure to better meet the needs of surgical patients. (Submitted by: American Academy of Ophthalmology)

  • (Early public comment)Submitted on behalf of: Jeffrey Plagenhoef, M.D. The American Society of Anesthesiologists supports the continued development of this measure with the goal of working collaboratively with the measure stewards to ensure all eligible clinicians who contribute to the intended patient outcomes this measure describes can be fairly and accurately assessed. Our members provide care to patients in a variety of facilities and care settings that include inpatient hospital settings, outpatient hospital departments, ASCs and office-based locations. Perioperative care is a complex, multidisciplinary process involving several care teams working together and this measure has the opportunity to demonstrate the role physician anesthesiologists play in protecting patient safety, contributing to population health and improving patient outcomes. ASA supports efforts to make the MIPS program more efficient and reduce the reporting burden on MIPS eligible clinicians. Measures that reflect the performance of both the facility and the MIPS eligible clinicians should be integrated into MIPS, where appropriate. ASA also supports the concept of providing the option to use these measures, when appropriately specified, as a proxy for an individual physician. We believe that this shared accountability can incentivize collaboration among physicians and the facilities in which they provide services. (Submitted by: American Society of Anesthesiologists )

  • (Early public comment)The American Association of Nurse Anesthetists (AANA) appreciates the opportunity to provide comments regarding the FY/CY 2019 measures under consideration submitted to the MAP Clinician Work Group. The AANA has noted that the American College of Surgeons (ACS) has submitted Measure 291 for reporting patient experience with surgical care based on the Consumer Assessment of Healthcare Providers and Systems (CAHPS)® Surgical Care Survey (S-CAHPS) under MIPS. The language used throughout the S-CAHPS includes the term “anesthesiologist” without regard to any other anesthesia provider. Certified Registered Nurse Anesthetists (CRNAs) personally administer more than 40 million anesthetics to patients each year in the United States and in some states are the sole anesthesia providers in nearly 100 percent of rural hospitals. Nationally, CRNAs provide the same anesthesia services and patient assessments as anesthesiologists; therefore, the term “anesthesiologist” should be changed to “anesthesia provider” in the S-CAHPS if this measure is to be implemented under MIPS. Sincerely, Wanda O. Wilson, PhD, MSN, CRNA CEO/American Association of Nurse Anesthetists Lorraine M. Jordan, PhD, CRNA, CAE, FAAN Senior Director of Research and Quality/AANA (Submitted by: American Association of Nurse Anesthetists (AANA) )

Patient-Centered Surgical Risk Assessment and Communication (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-293)
  • (Early public comment)Overview The American College of Surgeons (ACS) is eager to promote the concept of measuring a patients “phases of care,” beginning with the Surgical Phases of Care Measures (SPCM) which is a patient-centered, comprehensive, and cross cutting approach to surgical measurement. The SPCM includes all measures which have been noted as by CMS on the MUC list as the “Group measure as defined by Am. Coll. of Surgeons.” However, based on the MAP Coordinating Committee’s criteria for inclusion of measures in national programs, we agree that MUC measures presented to the NQF MAP should be further tested for demonstration of the various aspects of feasibility, reliability, usability and validity. We have concerns that our initial surgical SPCM measure set does not have the level of rigorous analysis the ACS typically provides to the NQF or MAP. Therefore, we respectfully would prefer to initially include these measures in the ACS Qualified Clinical Data Registry (QCDR) , and potentially in an Advanced APM program prior to national implementation in the MIPS program. This would provide the ACS and the NQF MAP the level of confidence needed before promoting full scale deployment in the MIPS program. Therefore, we seek the NQF MAP’s support in the “direction” of this surgical measure framework. Background and Rationale Every surgical patient in each specialty walks through the phases of surgical care, and each of these phases involves key processes, critical care coordination with primary care physicians and anesthesia, as well as the technical side of surgical care that relates to safety, outcomes and preventing avoidable harms. As we move toward value-based surgical care system, a framework that values these phases is required. These metrics are different from measures in the current MIPS program because they broadly apply to almost all surgeons, span across the various phases of surgical care (preoperative, perioperative, intraoperative, postoperative, post discharge), and when measured together they can have a real impact at the point of care. The SPCM measure framework was constructed to allow for more detailed, procedure-specific metrics and patient reported outcome measures to be added when necessary. We believe this measure framework also aligns well with CMS’ efforts in episode based care and other alternative care programs. SPCM Measures as a Group On the MUC list, CMS notes that the SPCM measure was submitted by ACS as a measures group. It is important to clarify that it is not the intention of the ACS that surgeons would report across a “group” of seventeen measures. The reporting burden for reporting seventeen measures coupled with denominators that span across nearly all surgical patients would be extremely onerous. Rather, we would encourage surgeons to choose the required number of measures in MIPS (six measures, including one outcome measures) from the SPCM set and that those six measures span across the phases of surgical care. In an alternative payment model, select SPCMs can be rolled into a composite. We encourage future conversations on group reporting across a broader set of measures once interoperability and data exchange is enabled to the extent that would allow for easy flow of data to be captured across all surgical patients and thereby drastically reduce the reporting burden. However, we are many years away from the level of interoperability that would enable that level of data flow. (Submitted by: The American College of Surgeons)

Intravesical Bacillus Calmette-Guerin for NonMuscle Invasive Bladder Cancer (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-310)
  • (Early public comment)Bladder cancer is a significant malignancy and is the 5th common cancer diagnosis and affects both men and women. It is important to treat bladder cancer at the nonmuscle invasive stage as failure to do so canFailure to diagnose and treat early stage disease leads to invasion to the muscle layer of the bladder. Muscle invasion indicates an aggressive form of the disease that has an increased propensity to spread to other parts of the body. Therefore, it is important to treat bladder cancer at the nonmuscle invasive stage. Treatment of muscle invasive bladder cancer requires chemotherapy/radiation and removal of the bladder. This aggressive treatment involves significant morbidity, cost, and change in quality of life. This measure emphasizes the use of standard guidelines as well as proper timing for the initiation of Bacillus Calmette-Guerin (BCG). Although regular standard of care surveillance is required, a higher quality of life is maintained for the patient when the bladder is preserved. This is a MIPS e-clinical quality measure and has been tested in more than 1 EHR for ease of reporting. This measure doesn’t start until a definitive nonmuscle invasive bladder cancer diagnosis is determined and then has a healing time for up to 6 months for the BCG to be started. Intermittently, there are BCG production shortages which can affect this measure, but which are considered within the exclusionary criteria. This measure would be used for MIPS reporting. It promotes a high quality of bladder cancer care and would not be a topped out measure. (Submitted by: Oregon Urology Institute)

  • (Early public comment)This is a good measure based on Level I evidence and there are several studies showing poor use so the opportunity for improvement is large. Better use of BCG would reduce disease progression and use of highly co-morbid additional therapies. As currently written, however, this measure is inappropriately broad and will induce overuse of BCG among some patient who do not qualify, thus potentially exposing them unnecessarily to the rare but significant risks of intravesical BCG therapy. This can easily be corrected by adding several exclusion criteria to the measure: Low Grade Ta disease, mixed histology UCC tumors, including micropapillary, plasmacytoid, sarcomatoid, adenocarcinoma and squamous disease, patients who undergo cystectomy, chemotherapy or radiotherapy within 6 months of diagnosis, and all patient with a second primary malignancy. Finally, the wording and examples for the exclusion criteria of immunosuppressed patents could be improved to indicate that the disease listed are examples and not the only conditions that are considered immunosuppressed. I would also include examples like patients who are on steroids or any systemic chemotherapy. For clarity's sake, I would state in the inclusion criteria that this measure only applies to urothelial cell cancer. As far as the benefit/burden of impact vs. data collection, I think this will be beneficial, though there will be a data collection burden to contend with. This measure will be great for QI efforts. (Submitted by: UCLA)

Intraoperative Surgical Debriefing (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-316)
  • (Early public comment)Overview The American College of Surgeons (ACS) is eager to promote the concept of measuring a patients “phases of care,” beginning with the Surgical Phases of Care Measures (SPCM) which is a patient-centered, comprehensive, and cross cutting approach to surgical measurement. The SPCM includes all measures which have been noted as by CMS on the MUC list as the “Group measure as defined by Am. Coll. of Surgeons.” However, based on the MAP Coordinating Committee’s criteria for inclusion of measures in national programs, we agree that MUC measures presented to the NQF MAP should be further tested for demonstration of the various aspects of feasibility, reliability, usability and validity. We have concerns that our initial surgical SPCM measure set does not have the level of rigorous analysis the ACS typically provides to the NQF or MAP. Therefore, we respectfully would prefer to initially include these measures in the ACS Qualified Clinical Data Registry (QCDR) , and potentially in an Advanced APM program prior to national implementation in the MIPS program. This would provide the ACS and the NQF MAP the level of confidence needed before promoting full scale deployment in the MIPS program. Therefore, we seek the NQF MAP’s support in the “direction” of this surgical measure framework. Background and Rationale Every surgical patient in each specialty walks through the phases of surgical care, and each of these phases involves key processes, critical care coordination with primary care physicians and anesthesia, as well as the technical side of surgical care that relates to safety, outcomes and preventing avoidable harms. As we move toward value-based surgical care system, a framework that values these phases is required. These metrics are different from measures in the current MIPS program because they broadly apply to almost all surgeons, span across the various phases of surgical care (preoperative, perioperative, intraoperative, postoperative, post discharge), and when measured together they can have a real impact at the point of care. The SPCM measure framework was constructed to allow for more detailed, procedure-specific metrics and patient reported outcome measures to be added when necessary. We believe this measure framework also aligns well with CMS’ efforts in episode based care and other alternative care programs. SPCM Measures as a Group On the MUC list, CMS notes that the SPCM measure was submitted by ACS as a measures group. It is important to clarify that it is not the intention of the ACS that surgeons would report across a “group” of seventeen measures. The reporting burden for reporting seventeen measures coupled with denominators that span across nearly all surgical patients would be extremely onerous. Rather, we would encourage surgeons to choose the required number of measures in MIPS (six measures, including one outcome measures) from the SPCM set and that those six measures span across the phases of surgical care. In an alternative payment model, select SPCMs can be rolled into a composite. We encourage future conversations on group reporting across a broader set of measures once interoperability and data exchange is enabled to the extent that would allow for easy flow of data to be captured across all surgical patients and thereby drastically reduce the reporting burden. However, we are many years away from the level of interoperability that would enable that level of data flow. (Submitted by: American College of Surgeons)

Safety Concern Screening and Follow-Up for Patients with Dementia (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-317)
  • (Early public comment)Thank you for your consideration of the measures submitted by the American Academy of Neurology (AAN) and inclusion of the Safety Concern Screening and Follow-Up for Patients with Dementia measure in the Measures Under Consideration (MUC) list. However, while we appreciate the inclusion of this measure on the MUC list, the AAN still believes that there is a lack of specialty measures under consideration for the MIPS program; we believe that as the program continues to evolve the lack of specialty specific measures will pose a greater burden to participants. We also ask for greater transparency on the types of measures that CMS is looking to include in the program; this will assist measure developers in producing measures which will be applicable to public reporting programs. (Submitted by: American Academy of Neurology)

  • (Early public comment)The Alzheimer’s Association appreciates inclusion of this measure. (Submitted by: Alzheimer's Association)

  • (Early public comment)AOTA supports this inclusion of this measure in the MIPS program. The numerator includes specific and important measurement constructs. Screening for safety concerns and providing follow-up when these concerns are identified are critical for persons with dementia. We believe that this measure can meaningfully contribute to improved clinical care. By identifying safety concerns, practitioners such as occupational therapists can work with patients to reduce the chance of accident and injury which may result in hospital admission. Appropriate services to mitigate safety concerns may allow persons wtih dementia to maintain the ability to participate in meaningful activities and remain in the patient's preferred living environment. (Submitted by: American Occupational Therapy Association)

  • (Early public comment)It is well established that behavioral health disorders are the largest cost driver in the US with a price tag of over $200 billion annually (Roehring, C Hlth Aff 2016 35 (6)). Annual anxiety prevalence is 18% which is greater than that of depression at 6.6% annually (NIMH 2016 https://www.nimh.nih.gov/health/statistics/index.shtml). In the Department of Health and Human Services’ (HHS) Top 20 High-Impact Medicare Conditions Crosswalk (2015 National Impact Assessment of CMS Quality Measures Report) major depression is ranked number one. This HHS report lists cardiovascular, diabetes, cerebrovascular, and cancer as the next highest high-impact disorders. Thirty-five percent of patients with chronic medical conditions have a mental illness (2014 Milliman Report for the American Psychiatric Association). The underdiagnosed and undertreated mental health disorders in these high-impact categories should be expanded, addressing these unmet patient needs in order to improve outcomes, decrease costs and improve the experience of patients. There should be a national imperative to diagnose and treat these conditions in primary and specialty care considering the prevalence and comorbidity with chronic medical conditions. Use of multidimensional mental health screens that provide measures can drive the healthcare system to higher performance and can be accomplished through minimal disruption in clinical workflow. M3 recommends the adoption of measures that incentivize comprehensive assessment of a patient’s risk for a behavioral health condition and fit seamlessly into the physician workflow. M3 is appreciative of the MUCs listed that incorporate behavioral health issues such as: • tobacco use screening & treatment (MUC16-50 to 52) • alcohol screening & treatment (MUC16-178 to 180) • opioid safety, screening & use (MUC16-167 & 428) • anxiety related to hospice care (MUC16-39) • harm to self for patients with dementia & their caregivers (MUC16-317) The current list of MUC touches on several mental health issues in tangential ways as seen from the list above. The MAP can drive the healthcare system to higher performance through the use mental measurement system that can be used across healthcare settings, reports functional status, addresses patient safety, provides longitudinal comparisons, reports results electronically, and fills gaps for multiple behavioral health conditions, rather than just depression. With this in mind M3 recommends NQF endorse multidimensional measures with a similar to NQF-2620. NQF-2620 measures the percentage of people in primary care settings who have had an annual multi-dimensional mental health screening assessment, which is operationally defined as "a validated screening tool that screens for the presence or risk of having the more common psychiatric conditions, which for this measure include major depression, bipolar disorder, PTSD, one or more anxiety disorders (specifically, panic disorder, generalized anxiety disorder, obsessive-compulsive disorder, and/or social phobia), and substance abuse." (Kessler RC, NEJM 2005; 352(24): 2515) among the most common behavioral health conditions, and there exist multi-dimensional behavioral health assessment tools that can be used across primary and specialty care settings (Kennedy Forum 2016, A Core Set of Outcome Measures for Behavioral Health Across Service Settings). MUC16-317 (safety concern harm to self or others w dementia) – Harm to others and self are a risk for individuals with dementia and is a significant concern. Suicidality is on the rise in the US with the rate increasing by 24 percent from 1999 to 2014. All patients, including those with dementia, should routinely be assessed for risk of suicidality. M3 recommends the use of multidimensional screening and measurement for diagnoses related to suicide such as depression, anxiety, PTSD, and bipolar disorder. This type of assessment simultaneously screens and measures for risk of multiple mental health and substance use disorders and decreases the clinical workflow burden. The challenge is the lack of multidimensional measures. (Submitted by: M3 Information, 155 Gibbs St #522 Rockville, MD 20850)

Post-Discharge Review of Patient Goals of Care (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-345)
  • (Early public comment)Overview The American College of Surgeons (ACS) is eager to promote the concept of measuring a patients “phases of care,” beginning with the Surgical Phases of Care Measures (SPCM) which is a patient-centered, comprehensive, and cross cutting approach to surgical measurement. The SPCM includes all measures which have been noted as by CMS on the MUC list as the “Group measure as defined by Am. Coll. of Surgeons.” However, based on the MAP Coordinating Committee’s criteria for inclusion of measures in national programs, we agree that MUC measures presented to the NQF MAP should be further tested for demonstration of the various aspects of feasibility, reliability, usability and validity. We have concerns that our initial surgical SPCM measure set does not have the level of rigorous analysis the ACS typically provides to the NQF or MAP. Therefore, we respectfully would prefer to initially include these measures in the ACS Qualified Clinical Data Registry (QCDR) , and potentially in an Advanced APM program prior to national implementation in the MIPS program. This would provide the ACS and the NQF MAP the level of confidence needed before promoting full scale deployment in the MIPS program. Therefore, we seek the NQF MAP’s support in the “direction” of this surgical measure framework. Background and Rationale Every surgical patient in each specialty walks through the phases of surgical care, and each of these phases involves key processes, critical care coordination with primary care physicians and anesthesia, as well as the technical side of surgical care that relates to safety, outcomes and preventing avoidable harms. As we move toward value-based surgical care system, a framework that values these phases is required. These metrics are different from measures in the current MIPS program because they broadly apply to almost all surgeons, span across the various phases of surgical care (preoperative, perioperative, intraoperative, postoperative, post discharge), and when measured together they can have a real impact at the point of care. The SPCM measure framework was constructed to allow for more detailed, procedure-specific metrics and patient reported outcome measures to be added when necessary. We believe this measure framework also aligns well with CMS’ efforts in episode based care and other alternative care programs. SPCM Measures as a Group On the MUC list, CMS notes that the SPCM measure was submitted by ACS as a measures group. It is important to clarify that it is not the intention of the ACS that surgeons would report across a “group” of seventeen measures. The reporting burden for reporting seventeen measures coupled with denominators that span across nearly all surgical patients would be extremely onerous. Rather, we would encourage surgeons to choose the required number of measures in MIPS (six measures, including one outcome measures) from the SPCM set and that those six measures span across the phases of surgical care. In an alternative payment model, select SPCMs can be rolled into a composite. We encourage future conversations on group reporting across a broader set of measures once interoperability and data exchange is enabled to the extent that would allow for easy flow of data to be captured across all surgical patients and thereby drastically reduce the reporting burden. However, we are many years away from the level of interoperability that would enable that level of data flow. (Submitted by: American College of Surgeons)

Post-Discharge Review of Patient Goals of Care (Group measure as defined by Am. Coll. of Surgeons) (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-345)
  • (Early public comment)W. L. Gore and Associates recently conducted a scan of quality measures for aortic aneurysm (AA) repair. In our scan, we identified a number of measure gaps based on a comparison to clinical guideline recommendations and a review of factors that drive variation in quality and cost for AA treatment. This measure would fill an important measurement gap. Clinical guidelines from the Society for Vascular Surgery state that patient preference should help guide care for AA repair. This measure will help to ensure that patient preferences continue to be taken into account after AA repair procedures. (Submitted by: W. L. Gore and Associates)

Appropriate Use Criteria - Cardiac Electrophysiology (Program: Merit-Based Incentive Payment System; MUC ID: MUC16-398)
  • (Early public comment)Applying appropriate use criteria is a new regulatory requirement for some procedures and it seems reasonable to include these as quality measures. Monitoring will be required to determine if the measure tops-out quickly. (Submitted by: American Academy of Family Physicians)

  • (Early public comment)Anthem questions this inclusion of this measure. The measure details appear to be a statement rather than a measurement of care. (Submitted by: Anthem)


Appendix D: Instructions and Help

If you have any problems navigating the discussion guide, please contact us at: mapclinician@qualityforum.org. 

Navigating the Discussion Guide

  • How do I get back to the section I was just looking at?
    The easiest way is to use the back button on your browser. Other options are using your backspace button (which works for many browsers on laptops), or using the permanent links at the upper right hand corner of the discussion guide. But the back button is the best choice in most situations.

  • Can I print the discussion guide out?
    You can, but we don't recommend it. Besides using a lot of paper (probably a couple hundred pages at least), you'll lose all the links that allow you to move around the document. For instance, if you're scrolling through the agenda and want to see more information about a particular measure, the electronic format will allow you to click a link, read more, and then bo back. If you're on paper, there will be a lot of flipping through paper.

  • If I can't print this out, how can I read it on the plane?
    We will send you a pdf/Adobe Acrobat file a few days before the meeting, which will hopefully be useful when you're reviewing the discussion guide as you travel to Washington, DC.

  • How do I know that I'm looking at the most recent version?
    At the top left corner of the discussion guide is a version number. At the beginning of the in person meetings, the NQF staff will ask everyone to load the most recent discussion guide version and will check that everyone has the same version loaded.

  • What electronic devices can I use to view the discussion guide?
    We tried to make this as universal as possible, so it should work on your laptop (PC, Mac, Linux), your tablet (iPad, Android), or your phone (iPhone, Android). It should also work on many types of browsers (IE, Firefox, Chrome, Safari, Opera, Dolphin,....). Please let us know if you have any problems, and we'll troubleshoot with you (and improve the discussion guide for the next go around).

  • Why do I see weird characters in some places?
    Because we're joining data from many different sources, we do find some technical challenges. This generally shows up as strange characters--extra question marks, accented characters, or otherwise unusual items. We've been able to fix many of these problems, but not all. We ask that you bear with us as we improve this over time!

Content

  • What is included in the discussion guide?
    There are four sections within this document:
    • Agenda, with summaries of each measure under consideration
    • Full information about each measure, including its specifications, preliminary analysis of how this measure can advance the program's goals, and the rationale by HHS for being included in the list
    • Summaries for each federal health program being considered
    • Public comments that have been received to date (Note that the discussion guide may be released before the public comment period is finished, in which case there will just be a placeholder for where comments will go)

  • How are the meeting discussions organized?
    The meeting sessions are organized around consent calendars, which are groups of measures being considered for a particular program or groups of measures for a particular condition or topic area. For each measure being discussed, this document will show you the description, the public comments (if any), the summary of the preliminary analysis, and the result of the preliminary analysis algorithm.

Appendix E: Instructions for Joining the Meeting Remotely

Remote Participation Instructions:

Streaming Audio Online
  • Direct your web browser to: http://nqf.commpartners.com..
  • Under “Enter a Meeting” type in the meeting number for Day 1: 684579 or for Day 2: 244459
  • In the “Display Name” field, type in your first and last names and click “Enter Meeting.”
Teleconference
  • Dial (888) 802-7237 for workgroup members or (877) 303-9138 for public participants to access the audio platform.